CCC Maker - Worksite Evaluation Form

Please complete this form before placement of students at worksite location. Forward the sample work site agreement below in addition to the answers to the questions in this form.

Please select college.

Employer or Sponsor representative responsible for internship oversite and evaluation.

Employer/Business/Makerspace/Sponsorship Name

Employer/Business/Makerspace/Sponsorship Location

Industry/business/makerspace description

Duties to be performed at worksite.

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.

Please describe the process for which a portfolio will be used to evaluate the selection of the student in the options above. Include process like employer application, dates, or other processes which maybe internal to the college in order to prepare students for application.

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:

Please consider printing them and reviewing with students especially if performing work in locations which may not have these notices.
Download all here:

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

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