NAME:	MONTH/YEAR:

Rate the success of the month (Select one no., and say why it was so?)

Poor	Fair	Good	Very Good

1 2	3 4 5	6 7	8 9 10

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2.	List the major activities of the month and the approximate number of hours?

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3	What would you do differently if you could?

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4.	What did you read that was helpful? How was it helpful?

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5.	What did you learn from your Supervisor?

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6.	What did you learn about yourself?

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Student’s Signature: ____________________________________________	Date: ___________

Supervisor’s Signature: __________________________________________	Date: ___________

VP Student Affair’s Signature: _____________________________________	Date: ___________