APPENDIX-I DECLARATION
I Ms./Mr./Dr. ......................................................................... hereby declare that I am a Learner
of M.A. Psychology (Part II), January/ July _____ year, at the Study Centre Code __________
Regional Centre ________ and I want to do my Internship (MPCE-015/MPCE-025/MPCE-035)
at __________________________________ on my own free will. I will adhere to the standards
of the organization and display professionalism during my internship.
Signature of the Learner Date:
Name of the Learner: Place:
Enrollment No.:
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APPENDIX-II FORMAT FOR REFERENCE LETTER
Date:
To,
_______________________________
_______________________________
_______________________________
Dear Sir/ Madam,
This is state that Mr./ Ms. ____________________________________________, Enrollment
No. ___________________is a student of IGNOU and is presently pursuing MA in Psychology
from __________ Regional_________ Centre _________________________________, Study
Centre _____________________. As a part of MA Psychology programme he/ she has to carry
out internship (MPCE-015/MPCE-025/MPCE-035) for 240 hours. You are requested to kindly
provide him/her with permission to undergo internship at your esteemed organization.
You are also requested to assign one supervisor under whom the learner will carry out his/
her internship. The superviser will also have to evaluate the learner as per the given criteria.
Yours faithfully,
Academic Counsellor/Study-Centre Coordinator
/Regional Director
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APPENDIX-III CONSENT LETTER (Agency Supervisor)
This is to certify that the internship in MPCE-015/MPCE-025/MPCE-035 for the partial fulfillment
of MAPC Programme of IGNOU will be carried out by Mr./Mrs. _______________________
Enrollment No._____________________, under my supervision.
(Signature)
Name of the Agency Supervisor:
Designation:
Address:
Date:
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APPENDIX-IVRECORD OF VISITS/ACTIVITIES CARRIED BY LEARNER
Date of Time Duration Place Visited Nature of Work Name and Signature of Remarks
Visit From To Concerned Authority
46
Note:
• This includes visit to the organization/institute where the internship is carried out and interaction with the academic counsellor
allotted to the learner.
• This is to be duly signed and attached in the final Internship report.
• Multiple copies of the blank for can be taken.
Signature of the Learner Signature of Academic Counsellor
APPENDIX-V EVALUATION SCHEME FOR INTERNSHIP—
(AGENCY SUPERVISOR)
Name of the Programme: Course Code:
Study Centre: Regional Centre:
Name of the Learner:
Enrollment No.:
Internal Marks by Agency Supervisor
Details Maximum Marks Marks Obtained
Sincerity and professional competence 10
Assessment (Case history, Mental Status 15
Examination, Interview, Psychological
Testing etc.)
Overall interaction with patients, clients & 5
employees and handling of cases
Total Marks 30
Comments, if any: ____________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
Signature ________________
Name of Agency Supervisor
___________________________
___________________________
Date:
Note:
1. At the end of the Internship the marks are to be given by the Agency Supervisor in the above
format and is to be sent to the concerned study centre address in a sealed envelope.
2. The Study Centre will then send the marks given by the Agency Supervisor along with the
marks given by the Academic Counsellor to the Regional Centre while sending the Intership
Report of the Learners to the Regional Centre.
3. The marks given by the Agency Supervisor and the Academic Counsellor will be totalled
and entered in the Award Sheet during the TEE of the Internship at the·Regional Centre;
The total internal marks are 60.
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APPENDIX-VI EVALUATION SCHEME FOR INTERNSHIP—
(ACADEMIC COUNSELLOR)
Name of the Programme: Course Code:
Study Centre: Regional Centre:
Name of the Learner:
Enrollment No.:
Internal Marks by Academic Counsellor
Details Maximum Marks Marks Obtained
Report 20
Provisional diagnosis and Planning of 5
Intervention
Overall Understanding of Cases 5
Total Marks 30
Comments, if any: ____________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
Signature ________________
Name of Academic Counsellor
___________________________
___________________________
Date:
Note:
1. At the end of the Internship the marks are to be given by the Academic Counsellor.
2. The concerned Study Centre will then send the marks given by the Academic Counsellor
along with the marks given by the Agency Supervisor to the Regional Centre while sending
the Internship Reports of the Learners to the Regional Centre.
3. The marks given by the Academic Counsellor and the Agency Supervisor will be totalled
and entered in the Award Sheet during the TEE of the Internship at the Regional Centre. The
total internal marks are 60.
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APPENDIX-VII EVALUATION SCHEME FOR INTERNSHIP
(EXTERNAL EXAMINER)
Name of the Programme: Course Code:
Study Centre: Regional Centre:
Name of the Learner:
Enrollment No.:
External Marks (Viva Voce)
Details Maximum Marks Marks Obtained
Viva 40
Total Marks 30
Comments, if any: ____________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
Signature ________________
Name & Address of External Examiner
__________________________________
__________________________________
Date:
Note: The marks given by the External Examiner are to be entered in the Award Sheet along
with the internal marks received from the Study Centre at the time of TEE of Internship.
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APPENDIX-VIII CERTIFICATE
CERTIFICATE
This is to certify that Ms./Mr. _____________________________________________________
of MA Psychology Second Year (MAPC Programme) has conducted and successfully completed
the Internship in MPCE 015/ MPCE 025/ MPCE 035 (please tick one organisation/clinic/agency)
in the place __________________________________________________________________
Name: Name:
Enrollment No.: Designation:
Name of the Study Centre: Place:
Regional Centre: Date:
Place:
Date:
Signature of Agency Supervisor
Name:
Designation:
Name of the Organization:
Address:
Place:
Date:
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APPENDIX-IX FORMAT FOR INTERNSHIP REPORT
After the internship is carried out, you have to write an internship report. This is to be written
case wise or activity wise. It can include information that is typed or handwritten. A total of 10
cases/ activities need to be included in the internship report.
The format for internship report is as follows:
Title page: The report should have a title page that should include name of the leamer, enrolment
number and year, regional centre, the name of the organisation/institute where the internship
was carried out.
Certificate
Acknowledgement (Appendix-VIII)
Profile of the Organisation/Institution
Includes the details of the organisation institution like the main are of work, when the organisation
was established or started, details about trustees, management, organisational structure, activities
carried out and so on.
Record of visits/activities carried out by Learner (Appendix-IV).
Table of content
Reporting of the cases
Includes the reports for each case/activity. The reporting of cases will differ on the basis of
specialisation.
The cases/activities are to be reported as follows:
For Clinical Psychology and Counselling Psycbology
Each case should include the following:
1. Title of the case or number to be provided.
2. The case history in original should be attached.
3. Mental Status Examination, if carried out.
4. The psychological tests administered, if any.
5. Details about interview of significant others, like parents, spouse, friends, colleagues, children
etc. from whom the information was obtained can be included.
6. Any other relevant information.
7. Your observations of the case.
8. Intervention you feel needs to be provided.
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For Industrial and Organisational Psychology
Under Industrial and Organisational Psychology there can either be individual cases related to
absenteeism by an employee, alcoholism, problem behaviour, stress, anxiety etc. or it can be
related to activities related to processes like selection, performance appraisal, training,
organisational culture etc.
Each individual case should include the following:
1. Title of the case or number to be provided
2. The case history taken in original should be attached
3. The psychological tests administered, if any,
4. Any other relevant information
5. Your observations of the case
6. Intervention you feel needs to be provided
Each activity should include the following:
1. Suitable heading
2. Details about how a particular activity is carried out in that organization.
3. Details about interviews or questionnaires with regard to the activity that were carried out
or administered, if any.
4. Your observation of the case
5. Intervention you feel needs to be provided.
The Report should include the following:
1. Consent Letter duly signed by the agency supervisor (Appendix III).
2. Declaration duly signed by the learner (Appendix I).
3. Certificate duly signed by the learner, academic counselor and agency supervisor (Appendix
VIII).
4. Record of Visits/Activities carried by the learner (Appendix-IV).
Note: The learner should keep a photocopy of the Internship Report before submitting it.
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APPENDIX-X REMUNERATION BILL
To
The Regional Director
Regional Centre,
________________________
IGNOU
1. Programme Code: MAPC
2. Course Code: MPCE 015/025/035
3. Name of Supervisor (Academic Counsellor/Agency Supervisor/External Examiner):
Please put a (√ ) for the apprpriate option.
________________________________________________________
4. Residential Address: ________________________________________________________
_______________________________________________________________________
5. Designation: ______________________________________________________________
6. Official Address: ___________________________________________________________
_______________________________________________________________________
7. Telephone No. Office: _________________________
Mobile: ________________________
Residence: ______________________
Sl. No. Enrolment No. Name of Student Amount
53
Certified that I have supervised/conducted viva voce for the above students for their internship
work.
Dated: ____________ Signature of the Supervisor/examiner: ________________
Certified that the above examiner for internship work was approved and recommended by the
concerned school of study and above claim may be admitted.
Dy./ Asst. Registrar Section Officer Dealing Assistant
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APPENDIX-XI
ACKNOWLEDGEMENT
This is to acknowledge that Ms./Mr. .............................................................................................
Enrollment No. ........................................................ of MAPC (2nd Year) has submitted the
Internship Report at the Study Centre ............................................................................. Regional
Centre .................................................
Date: Signature (with stamp)
Received by
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NOTES
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