Academic Reporting
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
AM/PM
Time Out
Time Out
*
:
HH
MM
AM
PM
AM/PM
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