Intern Placement Request

This form should be submitted by a university supervisor OR intern requesting placement with Pasco County Schools.

Name of University Supervisor (HREQ will email the placement confirmation to the email address listed below) Name of University Supervisor (HREQ will email the placement confirmation to the email address listed below) First Last
Email of University Supervisor
Name of University
Is this a final intern placement request?

Is this a final intern placement request? Yes No
If not a final intern placement, select the internship level:

If not a final intern placement, select the internship level: Level 1 Level 2 Level 3 Other Other
If this is not a final internship placement, what day(s) and time(s) is the intern available?
Multiple Placements

If you have multiple interns to place, please upload a file containing:
Name, contact information, major, and preferred placement location if applicable for each intern
Upload file requesting placements (Excel Format)

Attach Files
Individual Placements

Fill out the rest of the form to submit individual placement requests.
Intern Name Intern Name First Last
Address Address
Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country
Phone Phone - ### - ### ####
Email
Please list the schools requested for placement in order of preference.
If you do not have specific school requests, please select an area of the county:

If you do not have specific school requests, please select an area of the county: West East Central
Intern's Major
List specific content and/or grade level requests:
Start date of Placement: Start date of Placement: / MM / DD YYYY
End date of Placement: End date of Placement: / MM / DD YYYY
Please use this space to describe any requirements during the placement. Provide details regarding requirements (hours needed for student, CT Requirements: certification or clinical educator training).
Upload any supporting documents, in neccesary

Attach Files
*****FOR HREQ USE ONLY*****
Placement Status:
Reviewed by:
Placement School
Subject (if applicable)
Cooperating Teacher
Fingerprints
Cooperating Teacher is Clin Ed Trained?

Cooperating Teacher is Clin Ed Trained? Yes No
Additional Notes

Intern Placement Request

Intern Placement Request

Multiple Placements

Individual Placements

*****FOR HREQ USE ONLY*****

FOR HREQ USE ONLY