INTERNSHIP / VOLUNTEER PROGRAM PACKET
Individuals interested in Internship / Volunteer positions shall be required to provide to the Sponsoring
Departments the following documentation for assessment:
1. Intern / Volunteer Program Learning Agreement
2. Intern / Volunteer Information Sheet
3. Intern and Employment History
4. Intern Disclosure and Authorization Form (BACKGROUND CHECK FORM)
5. Intern / Volunteer Confidentiality Agreement
6. Intern / Volunteer Statement of Understanding
7. Criminal Background Check (BACKGROUND CHECK FORM)
8. Informed Consent
9. Current Resume or CV
10. Recommendation Letter
11. Recent Transcript
12. RBHS Internship Policy
INTERNSHIP PROGRAM LEARNING AGREEMENT
Intern Information
First Name:
Middle Initial:
Last Name:
Address:
City:
State:
Telephone#
Email Address:
Department Information
Department:
Unit/School:
Campus:
Account to be charged for physical exam:
Name of Supervisor:
Telephone:
Email Address:
Duration of Agreement:
From: / /
To: / /
Hours/Week:
Position Information
Internship Proposal (Including learning objectives of the internship, duties, responsibilities, and nature of
activities to be performed). Please use additional sheet of paper if needed
Required Signatures
Role
Signature
Date
Intern
Supervisor
Dean/CEO/VP
Human Resources
INTERN INFORMATION SHEET
Last Name:
Middle Initial:
First Name:
Address:
City:
State:
Zip:
Telephone#
Email Address:
EDUCATION (List name and Address of School)
High School:
Diploma
Equivalent
Last Year Completed:
Graduate
Yes
No
College/University:
Major Specialization:
Last Year Completed :
Graduate
Yes
No
Trade/Business School:
Last Year Completed :
Graduate
Yes
No
Diploma/Degree Received:
Graduate School:
Last Year Completed:
Graduate
Yes
No
Diploma/Degree Received:
PROFESSIONAL CERTIFICATION/LICENSE
License/Document #:
Type of Document:
Date Issued:
Expiration Date:
List Additional Skills:
BACKGROUND
Do you have a legal right to reside in the US?
Yes
No
If Yes, please enter Alien Registration #:
Naturalization #:
Date Issued:
Place:
Are you currently an employee of Rutgers in a legacy
UMDNJ position?
Yes
No
Were you previously an employee of Rutgers or
UMDNJ
Yes
No
If Yes, Please indicate the date:
From:
To:
Unit/School:
Department:
Do you have a relative that currently works for
Rutgers?
Yes
No
If Yes; Please enter name:
Have you ever been convicted of a crime or found /pled guilty of a disorderly offense or a Misdemeanor
(excludes any minor motor vehicle offenses):
Yes
No
If Yes please explain below; attach additional sheet if
needed
Why do you want to participate in an Internship Program:
INTERN INFORMATION SHEET
From:
To:
Employer:
Phone:
Address:
City:
State:
Zip:
Job Title:
Responsibilities:
Reason for leaving:
Immediate Supervisor:
Phone:
If currently Employed may we contact your employer
Yes
No
From:
To:
Employer:
Phone:
Address:
City:
State:
Zip:
Job Title:
Responsibilities:
Reason for leaving:
Immediate Supervisor:
Phone:
From:
To:
Employer:
Phone:
Address:
City:
State:
Zip:
Job Title:
Responsibilities:
Reason for leaving:
Immediate Supervisor:
Phone:
I hereby release from liability all persons, corporations, or other organizations furnishing information. I am aware that my
internship status with the University is conditional depending on the results of verification of references, licenses,
educational background, criminal background check, and if required, a physical examination. It is understood and agreed
that any misrepresentation, to the best of my knowledge and belief in this application will be sufficient cause for
cancellation of the application for an internship position, and/or termination of my internship. I hereby give Rutgers
University permission to investigate all references and to secure any additional information that may be required.
In accordance with Federal law, Rutgers University will not employ or enter into contracts or otherwise engage with any
individual or entity that is currently excluded by the Office of the Inspector General (OIG) and/or the General Service
Administration (GSA) from participating in Federal programs.
I have read the above statement and I do certify that I am not currently excluded by the OIG and/or the GSA from
participating in Federal healthcare programs.
Signature:
Date:
INTERN DISCLOSURE AND AUTHORIZATION FORM
In connection with my application for Internship at Rutgers, I understand that a consumer report or
investigative consumer report, as those terms are defined in the Federal Fair Credit Reporting Act as amended
(FCRA), 15 U S C 1681 et seq., may be obtained by Rutgers from a consumer reporting agency. I understand that
the report may include but not be limited to my consumer credit history, education, professional licensing,
professional liability claims history, criminal history, driving history, personal character, abilities, work habits,
charges of research misconduct, mode of living, residency, immigration status, general reputation,
performances, experience and other qualities pertinent to my qualifications for an internship, including reasons
for termination of past employments. I further understand that the consumer reporting agency may not give
out information about me to Rutgers without my written consent.
I understand that I am entitled to be informed if an internship is withheld because of information obtained from
the consumer reporting agency; and in that event, I have sixty (60) days within which to submit a written
request to the consumer reporting agency which will provide me with a copy of my file and a “Summary of Your
Rights Under the Fair Credit Reporting Act”
I hereby authorize Rutgers and affiliated clinical facilities where I may intern to obtain consumer reports in
connection with my application for internship at Rutgers. I authorize all former employers, listed references,
schools, law enforcement agencies and courts, to release to Rutgers and/or their representatives information
pertaining to me.
Note: The phrases and wording contained in this authorization are required under the FCRA. Rutgers will not run
a credit check as part of the investigation unless the internship for which applied requires financial information
on a prospective applicant. The applicant will be notified if a credit check is required.
PLEASE PRINT
Name:
Phone:
Email:
Other Name(s) used:
Applicant Signature:
INTERN CONFIDENTIALITY AGREEMENT
I understand that in the course of my internship experience I may have access to and be involved in the
processing of verbal, written, computer generated, computer accessed, filmed, and/or recorded information
related to clients, patients, employees, or University business.
I understand that I am required to maintain confidentiality of this direct or indirect information at all times,
both during and after my internship experience. I understand that I will not share, discuss, or reveal any of
this information to anyone.
I understand any breach of confidentiality may result in disciplinary action, including termination of my
internship, or legal action.
I certify by my signature that I acknowledge being informed of the confidentiality policy concerning
confidential information and its treatment. I agree to adhere to and uphold the private and privileged
information therein.
Intern Name:
Signature
Date:
Witnessed by
Supervisor/Mentor:
Signature of Supervisor/Mentor:
Date:
INTERN STATEMENT OF UNDERSTANDING
I, _____________________________________ understand and agree with the following conditions concerning
my Internship at Rutgers.
It is understood that Interns are not covered by the New Jersey Workers Compensation Act.
It is understood that if I am injured while Interning on Rutgers premises, the University will provide, at the time
of injury, reasonable emergency medical treatment for that injury without change, regardless of apparent fault;
and it is also understood that the provision of emergency medical service does not constitute an admission of
liability on the part of Rutgers.
Intern Signature:
Faculty Mentor:
Faculty Mentor Signature:
Supervisor:
Supervisor Signature:
Department:
Date:
If you have any questions or concerns, please contact the Senior Human Resources Generalist assigned to
your school or unit.
For the Stratford/Camden campuses, please call 856-566-6164
RUTGERS CRIMINAL BACKGROUND CHECK
First Name:
Middle Initial:
Last Name:
Other Name(s) You Have Used:
Date of Birth:
Telephone Number:
Email Address:
Please list all addresses for the past ten years. If more; please use the reverse side of this form
Full Street Address:
City:
State:
Zip:
Full Street Address:
City:
State:
Zip:
Full Street Address:
City:
State:
Zip:
HUMAN RESOURCES USE ONLY-Level IV Screening
Select report type by placing a check in the appropriate box
Newark
New Brunswick/Piscataway
Stratford/Camden
470 Regular Staff
473 Faculty
476 House staff
479 Volunteer Staff
482 Volunteer Faculty
915 Intern
470 Regular Staff
473 Faculty
476 House staff
479 Volunteer Staff
482 Volunteer Faculty
915 Intern
470 Regular Staff
473 Faculty
476 House staff
479 Volunteer Staff
482 Volunteer Faculty
915 Intern
Human Resources Generalist:
Date:
INFORMED CONSENT
Name of Student:
Will be participating in_________________________________________________________________
activity(s) on_____________________ at __________________________________________________
Furthermore, I recognize and acknowledge the following:
That participation is voluntary and it is at my own risk;
That travel to and from the site in a vehicle such a charter bus, car, or by a mode of public transportation, such as
train or subway, entails risks of bodily injury or property damage;
That I am physically able to participate in the activity and know of no disability that would prevent my
participation;
That while I am on the trip there are risks of bodily injury or property damage caused by or resulting from slips,
trips, falls and other forms or physical harm;
That participation in the trip takes place takes place in an urban environment, in which there is a possibility to
encounter unfortunate events, such as theft, physical assault, car accidents, separation from the participating
group, among others;
That in the event that a need for emergency medical services arises, I authorize and consent to such service being
provided and assume the cost thereof;
For any activity that I engage in, including providing my own transportation, which is not scheduled by Rutgers
staff, I assume full responsibility for my engagement in the said activity;
Notwithstanding these risks, I, for myself, and assigns do waive, release and discharge Rutgers, The State University of
New Jersey, its governors, trustees, officers, employees and agents from any agents from any and claims, demands,
actions, causes of actions, costs and expenses for and by reason of any personal injury, property damage, loss and expense,
which heretofore have been or hereafter may be sustained or suffered by me in consequence of and as a result certain
accident, casualty or event or my presence or activities in connection with this activity. I also agree to indemnify and hold
harmless Rutgers for injuries sustained either by me and/or caused by me to others during activity. Furthermore, I
acknowledge that the risks outlined above are not intended to be all-inclusive and voluntarily accept all risks known or
unknown.
Participant Name (print):
Date:
Participant Signature:
Emergency Contact’s Name:
Date: