CCC Maker - Internship Form and Worksite Assessment

Please complete this form at least 5 business days before the student begins the internship and before placement at worksite location.

Forward the sample work site agreement (link below) in addition to the Workers Compensation Questions at the bottom half of this form if you are placing a student at an employer site.

https://drive.google.com/open?id=18F4Kss4MlswGP-QHjLo2uuggdHO9Hem3

FCCC Client*
Please select college.

College representative*
Time Keeper Supervisor

College Representative Email*
Time Keeper Supervisor Email

Student Information
Information below is required for all internships regardless of employer site.

Student Phone Number (Optional, but highly recommended)
Student will be receive a link for the Career Catalyst Employment Registration and Instructions within 5 minutes.

(123) 456-7890
or
123-456-7890

Internship Schedule
Use the Start and End Date (both required) and as many of the in-between days necessary. Total Hours must equal 20. Error message will be sent if the start date is within 5 days of today. If more than 8 days are necessary, please place as comments in text box at the end.

Schedule Comments
Place additional dates or details of schedule.

Job Description*
Describe the opportunity by stating the situation and environment the student will be performing the internship.

Desired Qualifications*
Knowledge, skills, and abilities to successfully perform the internship. Used in application and portfolio review.

Learning Outcomes*
Student outcomes which are SMART (specific, measurable, action-oriented, relevant, and time-based) and used for evaluation at the conclusion of the internship. Please number if more then one. i.e. 1., 2. 3., etc

Internship Option*
Please select one.
https://drive.google.com/file/d/1KaH8f0V1zO14_IaM044C82TfMJj2vrLx/view?usp=sharing

If Option 1 is selected, a followup email will ask for the Worksite Agreement (template link at top of page).

If students working at a college or under the supervision of college staff, select Option 2.

Worker's Compensation Information (Necessary if Option 1 selected above)
Please fill out if new employer or if student is to attend an employer site.

Worksite / Employer
Employer/Business/Makerspace/Sponsorship Name

Worksite Address
Employer/Business/Makerspace/Sponsorship Location

Work Site Description
Industry/business/makerspace description

Employer Interviewed

Workers Compensation Class Code

Workers Compensation Claims
Describe previous workers compensation claims, especially departments with excessive reporting.

Prior Accidents
Describe typical accidents and their frequency for the current and past years.

Is lifting required?

Lifting

Do you maintain OSHA 300 Logs and MSDS data sheets? (We may review current and prior years.)

OSHA

Do you have safety policies and/or an injury and illness prevention program (IIPP) in place?

Safety Policies/IIPP

Do employees receive written safety & personal protective equipment procedures?

Protective Equipment Procedures

Do employees receive written emergency procedures?

Emergency Procedures

Are there written procedures in place to ensure employees comply with safety practices?

Written Procedures

Do employees receive the following training and is it documented?

Safety Orientation

Do employees receive the following training and is it documented?

Hazard Communication

Do employees receive the following training and is it documented?

Material Safety Sheets

Is there a procedure to identify, evaluate, and correct workplace hazards?

Correct Hazards

Personal Protective Equipment Information
Please list the required and provided equipment. The fields are prefilled with examples. Add or remove equipment as necessary.

Protective Equipment Required
Add or remove additional type of protection.

Protective Equipment Provided
Add or remove additional type of protection.

Protective Equipment Description
Add or remove additional type of equipment.

Worksite Evaluation
Please indicate your impressions after a walk through of work site.

Are aisles and passageways clear?