Site or Supervisor Status Form

Authorized Site Representative*

First NameLast Name
Authorized Site Representative Email:*
example@example.com
Local Supervisor*

First NameLast Name
Local Supervisor Email:*
example@example.com
Students are able to leave sites, but they generally need to provide a month’s notice to their site. Please provide us with the responses below to the following, in order to ethically exit your site:

**A copy of the below responses will be sent to your site and local supervisor.
The end date of clinical internship at the site:*

MonthDayYear
Date
Do you plan on returning to your site in the future?

NoYes, I am taking a leave and will return at a later date
If you selected yes to the above question, please provide a date you will return to your site:*

MonthDayYear
Date
How you ethically and appropriately plan to conclude your time with your clients*
The status of all required documentation for your clients*
Any belongings that need to be returned to the site and how that will be accomplished*
Any other termination/closing requirements that the site indicates to you*
A statement that you will delete any and all recordings of the site's clients by your final date there*
Signature*

Clinical Team Admin Page
Please add any other pertinent details to this student's withdrawal from site, course, or university as applicable:
File Upload

Cancelof
Should be Empty:

This form notifies National University of your resignation from a site or supervisor, or a temporary leave from your site.