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KENTUCKY STATE UNIVERSITY 400 EAST MAIN STREET FRANKFORT, KENTUCKY 40601
Date Submitted: ___
Date Submitted
Student Name: ___
Student Name
Identification Number: ___
Identification Number
Required Number of Field Hours: ___
Required Number of Field Hours
Completed Number of Field Hours: ___
Completed Number of Field Hours
Reason for requesting an extension (Please attach documentation):
Sickness Death Family Emergency Other:___
Other
Death
documentation):
Plan of Action to Complete the Hours:___
Plan of Action to Complete the Hours [1]
Plan of Action to Complete the Hours [2]
Plan of Action to Complete the Hours [3]
Plan of Action to Complete the Hours [4]
Plan of Action to Complete the Hours [5]
Plan of Action to Complete the Hours [6]
Student Signature: ___
Student Signature
Instructor Signature: ___
Instructor Signature
Coordinator of Field Hours Signature: ___
Coordinator of Field Hours Signature
Chair of the Department Signature: ___
Chair of the Department Signature
Agreed Date for completion of hours: ___
Agreed Date for completion of hours
Date Completed: _____
Date Completed