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




Please select college.


Time Keeper Supervisor


Time Keeper Supervisor Email



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






Student will be receive a link for the Career Catalyst Employment Registration and Instructions within 5 minutes.

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






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.


































Place additional dates or details of schedule.





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


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


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


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.




Please fill out if new employer or if student is to attend an employer site.


Employer/Business/Makerspace/Sponsorship Name


Employer/Business/Makerspace/Sponsorship Location


Industry/business/makerspace description










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


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



Mark box to indicate "Yes".













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


Add or remove additional type of protection.


Add or remove additional type of protection.


Add or remove additional type of equipment.



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





















Official website: http://www.dir.ca.gov/wpnodb.html

Please consider printing them and reviewing with students especially if performing work in locations which may not have these notices.
Download all here: https://drive.google.com/open?id=1VkPdl3_x1SsAbOS7Y5HyL57Y6jddYGaJ







http://www.dir.ca.gov/dosh/dosh_publications/shpstreng012000.pdf



http://www.edd.ca.gov/pdf_pub_ctr/de1857a.pdf


http://www.edd.ca.gov/pdf_pub_ctr/de1857d.pdf








https://www.dol.gov/whd/regs/compliance/posters/eppabw.pdf









e.g.Employer Application, Internship Program, Documents (Forms, trainings, presentations, etc) Multiple files can be attached.






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