Internship Appendixs

APPENDIX-I DECLARATION
I Ms./Mr./Dr. ......................................................................... hereby declare that I am a Learner
of M.A. Psychology (Part II), January/ July _____ year, at the Study Centre Code __________
Regional Centre ________ and I want to do my Internship (MPCE-015/MPCE-025/MPCE-035)
at __________________________________ on my own free will. I will adhere to the standards
of the organization and display professionalism during my internship.
Signature of the Learner Date:
Name of the Learner: Place:
Enrollment No.:
43
APPENDIX-II FORMAT FOR REFERENCE LETTER
Date:
To,
_______________________________
_______________________________
_______________________________
Dear Sir/ Madam,
This is state that Mr./ Ms. ____________________________________________, Enrollment
No. ___________________is a student of IGNOU and is presently pursuing MA in Psychology
from __________ Regional_________ Centre _________________________________, Study
Centre _____________________. As a part of MA Psychology programme he/ she has to carry
out internship (MPCE-015/MPCE-025/MPCE-035) for 240 hours. You are requested to kindly
provide him/her with permission to undergo internship at your esteemed organization.
You are also requested to assign one supervisor under whom the learner will carry out his/
her internship. The superviser will also have to evaluate the learner as per the given criteria.
Yours faithfully,
Academic Counsellor/Study-Centre Coordinator

/Regional Director
44
APPENDIX-III CONSENT LETTER (Agency Supervisor)
This is to certify that the internship in MPCE-015/MPCE-025/MPCE-035 for the partial fulfillment
of MAPC Programme of IGNOU will be carried out by Mr./Mrs. _______________________
Enrollment No._____________________, under my supervision.
(Signature)
Name of the Agency Supervisor:
Designation:
Address:
Date:
45
APPENDIX-IVRECORD OF VISITS/ACTIVITIES CARRIED BY LEARNER
Date of Time Duration Place Visited Nature of Work Name and Signature of Remarks
Visit From To Concerned Authority
46
Note:
• This includes visit to the organization/institute where the internship is carried out and interaction with the academic counsellor
allotted to the learner.
• This is to be duly signed and attached in the final Internship report.
• Multiple copies of the blank for can be taken.
Signature of the Learner Signature of Academic Counsellor

APPENDIX-V EVALUATION SCHEME FOR INTERNSHIP—
(AGENCY SUPERVISOR)
Name of the Programme: Course Code:
Study Centre: Regional Centre:
Name of the Learner:
Enrollment No.:
Internal Marks by Agency Supervisor
Details Maximum Marks Marks Obtained
Sincerity and professional competence 10
Assessment (Case history, Mental Status 15
Examination, Interview, Psychological
Testing etc.)
Overall interaction with patients, clients & 5
employees and handling of cases
Total Marks 30
Comments, if any: ____________________________________________________________

____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
Signature ________________
Name of Agency Supervisor
___________________________
___________________________
Date:
Note:
1. At the end of the Internship the marks are to be given by the Agency Supervisor in the above
format and is to be sent to the concerned study centre address in a sealed envelope.
2. The Study Centre will then send the marks given by the Agency Supervisor along with the
marks given by the Academic Counsellor to the Regional Centre while sending the Intership
Report of the Learners to the Regional Centre.
3. The marks given by the Agency Supervisor and the Academic Counsellor will be totalled
and entered in the Award Sheet during the TEE of the Internship at the·Regional Centre;
The total internal marks are 60.
47
APPENDIX-VI EVALUATION SCHEME FOR INTERNSHIP—
(ACADEMIC COUNSELLOR)
Enrollment No.:
Internal Marks by Academic Counsellor
Report 20
Provisional diagnosis and Planning of 5
Intervention
Overall Understanding of Cases 5
Total Marks 30
Comments, if any: ____________________________________________________________

____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
Signature ________________
Name of Academic Counsellor
___________________________
___________________________
Date:
Note:
1. At the end of the Internship the marks are to be given by the Academic Counsellor.
2. The concerned Study Centre will then send the marks given by the Academic Counsellor
along with the marks given by the Agency Supervisor to the Regional Centre while sending
the Internship Reports of the Learners to the Regional Centre.
3. The marks given by the Academic Counsellor and the Agency Supervisor will be totalled
and entered in the Award Sheet during the TEE of the Internship at the Regional Centre. The
total internal marks are 60.
48
APPENDIX-VII EVALUATION SCHEME FOR INTERNSHIP
(EXTERNAL EXAMINER)
Enrollment No.:
External Marks (Viva Voce)
Viva 40
Total Marks 30
Comments, if any: ____________________________________________________________

____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
Signature ________________
Name & Address of External Examiner
__________________________________
__________________________________
Date:
Note: The marks given by the External Examiner are to be entered in the Award Sheet along
with the internal marks received from the Study Centre at the time of TEE of Internship.
49
APPENDIX-VIII CERTIFICATE
CERTIFICATE
This is to certify that Ms./Mr. _____________________________________________________

of MA Psychology Second Year (MAPC Programme) has conducted and successfully completed
the Internship in MPCE 015/ MPCE 025/ MPCE 035 (please tick one organisation/clinic/agency)
in the place __________________________________________________________________
Name: Name:
Enrollment No.: Designation:
Name of the Study Centre: Place:
Regional Centre: Date:
Place:
Date:
Signature of Agency Supervisor
Name:
Designation:
Name of the Organization:
Address:
Place:
Date:
50

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APPENDIX-I DECLARATION

I Ms./Mr./Dr. ......................................................................... hereby declare that I am a Learner

Regional Centre ________ and I want to do my Internship (MPCE-015/MPCE-025/MPCE-035)

at __________________________________ on my own free will. I will adhere to the standards

of the organization and display professionalism during my internship.

Signature of the Learner Date:

Name of the Learner: Place:

Dear Sir/ Madam,

This is state that Mr./ Ms. ____________________________________________, Enrollment

No. ___________________is a student of IGNOU and is presently pursuing MA in Psychology

from __________ Regional_________ Centre _________________________________, Study

Centre _____________________. As a part of MA Psychology programme he/ she has to carry

provide him/her with permission to undergo internship at your esteemed organization.

Academic Counsellor/Study-Centre Coordinator

of MAPC Programme of IGNOU will be carried out by Mr./Mrs. _______________________

Enrollment No._____________________, under my supervision.

Name of the Agency Supervisor:

Signature of the Learner Signature of Academic Counsellor

Comments, if any: ____________________________________________________________

Comments, if any: ____________________________________________________________

Comments, if any: ____________________________________________________________

This is to certify that Ms./Mr. _____________________________________________________

Enrollment No.: Designation:

Name of the Study Centre: Place:

Regional Centre: Date:

Signature of Agency Supervisor

Name of the Organization:

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from ______ Regional_ Centre _____________________________, Study