1. How many years have you been practicing law or if a judge, how many years have you been on the bench (three years in total required)  

2. Please check the fields that best describe the main areas of practice (up to 4) to which a practicum student may be exposed:

3. Please provide a general description of the practicum work the student will perform?

4. What skills may the student expect to practice? Check as many as apply and add your own categories as appropriate.

5. Please describe how you plan to supervise the practicum student with regard to orientation, guidance, and feedback relating to practicum work. Please note that weekly communication with the student is required.

6. Please select whether the practicum student will perform practicum work:
    at your worksite    on campus    both  

    If on campus, could the work be performed outside of normal business hours?
    Yes     No

7. If the student will perform the work at your worksite, is the worksite located in a building that meets the Americans with Disabilities guidelines?
    Yes    No    Unknown

8. How often would you be willing to undertake the supervision of a practicum student?
   One time only     On an as needed basis     Each semester (including summer)
   Other (please specify)

9. Please check all applicable boxes with regard to how the student should apply to complete the practicum under your supervision and information to be submitted:

If different from Supervisor information, please provide the following in regards to applications for the practicum:

10. May we post this practicum position on our Public Interest Practicum web page? (available to DU law students only - PASSWORD PROTECTED)    Yes     No
Please note, supervisors listed on our web page have the greatest chance of being contacted by our students.

11. May we publish a "link" to your web page from our web page to give students additional information about your organization?   Yes     No     N/A
   Web Page Address

12. By completing and signing this form, I understand and agree:

a) To provide a meaningful learning experience involving professional law-related work to a practicum student under my supervision.
b) To communicate at least weekly, or as appropriate given the time structure of the practicum, with a practicum student under my supervision to provide feedback, instruction, and guidance on practicum work.
c) To instruct a practicum student on confidentiality procedures and practices of my work setting and on any other rules of professional responsibility of importance in this setting.
d) To evaluate and resolve potential professional conflicts of interest with each practicum student.
e) That, in addition to 50 hours of practicum work, a student must complete an online Practicum Seminar, submit time sheets and a Student Evaluation of Practicum to the Public Interest Office but will be instructed to do so in a manner that does not reveal any confidential or identifying information.
f) To review with a practicum student my Student Performance Evaluation at the end of the practicum and submit the evaluation to the Public Interest Office by the given deadline. Such evaluation will be available for the practicum student to review.
g) That the Public Interest Office may call me to discuss the practicum and the progress of my practicum student and/or and to arrange an on-site visit in accordance with the ABA's accreditation standards for law schools.
h) To call the Public Interest Office if I have concerns or questions about the program or a practicum student.
i) Not to compensate a student for work done as part of a Public Interest Practicum.
j) Not to bill my clients (if any) for the time a student performs work as part of a Public Interest Practicum.
k) To maintain malpractice insurance coverage or confirm that I am immune from liability as a government agency.