Academic Reporting

To be completed by Instructor for all members of a course.

Name of Course Instructor Name of Course Instructor * First Last
Course # *
Course Title *
Email
Phone Phone - ### - ### ####
Date Date * / MM / DD YYYY
Number of Participants *
Agency
Location (City, State) *
Brief Description of Activities *
Did individuals receive academic credit or grade for participation? *

Did individuals receive academic credit or grade for participation? Yes No
**Travel Time not included
Time In Time In * : HH MM AM/PM
Time Out Time Out * : HH MM AM/PM
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Full Name

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