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
General Internship Information
FCCC Client
*
Please select college.
Allan Hancock College
American River College
Butte College
Cabrillo College
Chaffey College
City College of San Francisco
College of Alameda
College of San Mateo
College of the Canyons
Folsom Lake College
Foothill College
Glendale College
Golden West College
Hartnell College
Laney College
Moorpark College
Moreno Valley College
Mt. San Antonio College
Mt. San Jacinto College
Orange Coast College
Sacramento City College
San Bernardino Valley College
Sierra College
Woodland Community 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 name
*
Student Email
*
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
Pay rate
*
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.
Start Date
*
Start Date Hours
Day 2
Day 2 Hours
Day 3
Day 3 Hours
Day 4
Day 4 Hours
Day 5
Day 5 Hours
Day 6
Day 6 Hours
Day 7
Day 7 Hours
End Date
*
End Date Hours
Schedule Comments
Place additional dates or details of schedule.
Internship Description
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.
Option 1: Employer Site
Option 2: Team Project
Option 3: Entrepreneurship
Option 4: Retro
Option 5: Slingshot
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
Employer Email
Department
Workers Compensation Class Code
0005 NURSERIES - PROPAGATION AND CULTIVATION
0016 ORCHARDS - CITRUS AND DECIDUOUS FRUITS
0034 POULTRY RAISING
0035 FLORISTS - CULTIVATING OR GARDENING
0036 DAIRY FARMS
0038 STOCK FARMS
0040 VINEYARDS
0041 POTATO CROPS
0042 LANDSCAPE GARDENING
0044 COTTON FARMS
0045 ORCHARDS - NUT CROPS
0050 FARM MACHINERY OPERATION
0079 STRAWBERRY CROPS
0096 NUT HULLING, SHELLING OR PROCESSING
0106 TREE PRUNING, REPAIRING OR TRIMMING
0171 FIELD CROPS
0172 TRUCK FARMS
0251 IRRIGATION DRAINAGE OR RECLAMATION WORKS
0400 COTTON MERCHANTS - INCLUDING COMPRESSING
0401 COTTON GIN OPERATION
1122 MINING - SURFACE
1123 MINING - UNDERGROUND
1124 MINING - UNDERGROUND - SURFACE EMPLOYEES
1320 OIL/GAS LEASE OPERATORS
1322 OIL/GAS WELL SERVICING
1330 BLASTING
1438 SMELTING, SINTERING, REFINING, ALLOYING
1452 MINING - ORE MILLING
1463 ASPHALT WORKS
1624 QUARRIES
1699 ROCK WOOL MFG
1701 CEMENT MFG
1710 STONE CRUSHING
1741 SILICA GRINDING; TALC MILLS; PLASTER MILLS
1803 STONE CUTTING OR POLISHING; MARBLE CUTTONG OR POLISHING
1925 DIE CASTING MFG
2002 MACARONI MFG
2003 BAKERIES AND CRACKER MFG
2014 GRAIN OR RICE MILLING
2030 SUGAR MFG OR REFINING - BEET OR CANE
2063 CREAMERIES AND DAIRY PRODUCTS MFG
2081 BUTCHERING
2095 MEAT PRODUCTS MFG
2102 FRUIT OR VEGETABLE DEHYDRATING
2107 FRUIT - FRESH FRUIT PACKING
2108 FRUIT - CITRUS FRUIT PACKING
2109 FRUIT - DRIED FRUIT PACKING
2111 FRUIT OR VEGETABLE PRESERVING
2113 FISH OR SEAFOOD PRODUCTS MFG
2116 FRUIT JUICE OR CONCENTRATE MFG
2117 VEGETABLE OR FRUIT PROCESSORS - FROZEN
2121 BREWERIES OR MALT HOUSES
2123 FRUIT/VEGETABLE - FRESH - READY-TO-EAT
2142 WINERIES
2150 ICE MFG OR ICE DEALERS
2163 BOTTLING - BEVERAGES
2211 COTTON BATTING OR WASTE MFG
2222 SPINNING OR WEAVING
2362 KNITTING
2402 CARPET OR RUG MFG
2413 TEXTILES
2501 CLOTHING MFG
2570 MATTRESS OR BOX SPRING MFG
2571 PILLOW, QUILT OR CUSHION MFG
2576 AWNING, TARP OR CANVAS GOODS MFG
2584 CARPET, RUG OR UPHOLSTERY CLEANING
2585 LAUNDRIES
2589 DRY CLEANING OR LAUNDRY - RETAIL
2660 BOOT OR SHOE MFG
2683 BAG MFG - TRAVEL BAGS
2688 LEATHER GOODS MFG
2702 LOGGING OR LUMBERING
2710 SAWMILLS OR SHINGLE MILLS
2727 LOG HAULING
2731 PLANING OR MOULDING MILLS
2757 PALLET MFG, REPAIR, RECONDITION - WOOD
2759 BOX, BOX SHOOK OR CONTAINER MFG - WOOD
2790 PATTERN OR MODEL MFG
2797 MOBILE HOME MFG
2806 DOOR, SASH OR WINDOW MFG - WOOD
2812 CABINET MFG - WOOD
2819 TRUSS OR BUILDING COMPONENTS MFG - WOOD
2840 PICTURE FRAME ASSEMBLY - WOOD OR METAL
2842 WOOD PRODUCTS MFG
2852 WINDOW BLIND MFG
2881 FURNITURE ASSEMBLING - OTHER THAN METAL
2883 FURNITURE MFG - WOOD
2915 VENEER OR VENEER PRODUCTS MFG
2923 MUSICAL INSTRUMENT MFG - NOT METAL
3018 STEEL MAKING
3022 PIPE OR TUBE MFG - NOT IRON OR STEEL
3030 IRON OR STEEL WORKS - STRUCTURAL
3039 REINFORCING STEEL FABRICATION
3040 IRON WORKS - SHOP
3060 DOOR OR WINDOW MFG - METAL OR PLASTIC
3066 SHEET METAL PRODUCTS MFG
3070 COMPUTER MEMORY DISK MFG - RIGID
3076 FURNITURE MFG - METAL
3081 FOUNDRIES - IRON
3082 FOUNDRIES - STEEL CASTINGS
3085 FOUNDRIES - NON-FERROUS
3099 TOOL MFG - NOC
3110 FORGING WORKS
3131 TAG BUTTON OR FASTENER MFG
3146 HARDWARE MFG
3152 NAIL, TACK OR RIVET MFG
3165 AIR CONDITIONING/REFRIGERATION EQUIP MFG
3169 STOVE MFG
3175 FURNACE, HEATER OR RADIATOR MFG
3178 ELECTRONIC ELEMENT MFG
3179 ELECTRICAL APPARATUS MFG
3180 FIXTURES OR LAMP MFG OR ASSEMBLY
3220 CAN MFG
3241 WIRE ROPE OR CABLE MFG - WIRE DRAWING
3257 WIRE GOODS MFG
3339 FOUNDRIES - INVESTMENT CASTING
3365 WELDING OR CUTTING
3372 ELECTROPLATING
3383 JEWELRY MFG
3400 METAL GOODS MFG
3401 TUBE OR PIPE PRODUCTS MFG
3501 MACHINERY MFG - PORTABLE TOOL/LAWN CARE
3507 MACHINERY OR EQUIPMENT MFG
3560 MACHINERY MFG - COMMERCIAL - FOOD
3568 ELECTRICAL CONNECTOR MFG
3569 ELECTRIC MOTOR MFG OR REPAIR
3570 ELECTRIC APPLIANCE MFG
3572 MEDICAL INSTRUMENT MFG - ELECTRONIC
3573 POWER SUPPLY MFG
3574 MACHINE MFG - OFFICE OR SEWING
3577 PRINTED CIRCUIT BOARD ASSEMBLING
3612 PUMP/HYDRAULIC APPARATUS MFG OR REPAIR
3620 BOILERMAKING
3632 MACHINE SHOPS - NOC
3634 VALVE MFG
3643 ELECTRIC POWER/TRANS EQUIP MFG
3647 BATTERY MFG - STORAGE
3651 ELECTRICAL WIRE HARNESS MFG
3681 INSTRUMENT MFG - ELECTRONIC
3682 INSTRUMENT MFG - NON-ELECTRONIC
3683 SPEAKER MFG
3719 OIL/GAS REFINING UNITS ERECTION
3724 MILLWRIGHT WORK
3726 BOILER INSTALLATION REPAIR OR SETTING
3805 AIRCRAFT ENGINE MFG OR REBUILDING
3808 AUTO OR MOTORCYCLE MFG OR ASSEMBLING
3815 AUTO TRUCK OR AUTO TRUCK TRAILER MFG
3821 AUTO OR AUTO TRUCK PARTS DISMANTLING
3828 AUTO OR AUTO TRUCK PARTS REBUILDING
3830 AIRPLANE MFG
3831 MACHINE SHOPS - AIRCRAFT COMPONENTS
3840 AUTOMOBILE AND MOTORCYCLE PARTS MFG
4000 SAND OR GRAVEL DIGGING
4034 CONCRETE PRODUCTS MFG
4036 PLASTER BOARD OR PLASTER BLOCK MFG
4038 PLASTER STATUARY OR ORNAMENT MFG
4041 BRICK OR CLAY PRODUCTS MFG
4049 POTTERIES
4111 GLASSWARE MFG - NO AUTOMATIC MACHINES
4112 INTEGRATED CIRCUIT AND WAFER MFG
4114 GLASSWARE MFG
4130 GLASS MERCHANTS
4150 OPTICAL GOODS MFG
4239 PAPER OR PULP MFG
4240 BOX MFG - RIGID PAPER BOXES
4243 BOX MFG - FOLDING PAPER BOXES
4244 CORRUGATED OR FIBRE BOARD CONTAINER MFG
4250 PAPER COATING OR LAMINATING
4251 ENVELOPE MFG
4279 PAPER GOODS MFG
4283 BUILDING OR ROOFING PAPER PREPARATION
4286 BAG MFG - PLASTIC
4295 PRINTING - SCREEN - ALL OTHER EMPLOYEES
4297 ELECTRONIC PREPRESS
4299 PRINTING - ALL OTHER EMPLOYEES
4304 NEWSPAPER PUBLISHING
4312 NEWSPAPER DELIVERY
4351 PHOTO ENGRAVING
4354 PRINTED CIRCUIT BOARD MFG
4361 PHOTOGRAPHERS
4362 MOTION PICTURES - PROCESSORS
4410 RUBBER GOODS MFG
4420 RUBBER TIRE RECAPPING
4432 PEN OR MECHANICAL PENCIL MFG
4470 WIRE ROPE OR CABLE MFG - NO WIRE DRAWING
4478 PLASTIC GOODS MFG
4492 SIGN MFG - METAL, PLASTIC OR WOOD
4494 PLASTICS - BLOW MOLDED PRODUCTS MFG
4495 PLASTICS - EXTRUSION MOLDED PRODUCTS MFG
4496 PLASTICS - FABRICATED PRODUCTS MFG
4497 PLASTICS - FIBER REINFORCED PRODUCTS MFG
4498 PLASTICS - INJECTION MOLDED PRODUCTS MFG
4499 PLASTICS - THERMOFORMED PRODUCTS MFG
4511 ANALYTICAL OR TESTING LABORATORIES
4512 BIOMEDICAL RESEARCH LABORATORIES
4557 INK, MUCILAGE OR POLISH MFG
4558 PAINT, VARNISH OR LACQUER MFG
4611 DRUG, MEDICINE, OR PHARMACEUTICAL MFG
4623 COSMETIC OR PERSONAL CARE PRODUCTS MFG
4635 OXYGEN OR HYDROGEN MFG
4665 RENDERING OR FERTILIZER WORKS
4683 OIL MFG OR REFINING - VEGETABLE
4691 ORTHOTIC OR PROSTHETIC DEVICE MFG
4692 DENTAL LABORATORIES
4717 BUTTER SUBSTITUTES MFG
4720 SOAP OR SYNTHETIC DETERGENT MFG
4740 OIL REFINING - PETROLEUM
4771 EXPLOSIVE MFG
4828 CHEMICAL MIXING, BLENDING AND REPACKAGING
4829 CHEMICAL MFG
4831 VITAMIN OR FOOD SUPPLEMENT MFG
4922 MAGNETIC TAPE MFG
4983 GASKET MFG
5020 CEILING INSTALLATION - SUSPENDED
5027 MASONRY - LOW WAGE
5028 MASONRY - HIGH WAGE
5029 CONCRETE SAWING OR DRILLING
5040 IRON OR STEEL ERECTION - STRUCTURAL
5057 IRON OR STEEL ERECTION
5059 IRON OR STEEL ERECTION - UNDER 3 STORIES
5102 IRON/STEEL ERECTION - NON STRUCTURAL
5107 DOOR OR PRE-GLAZED WINDOW INSTALLATION
5108 DOOR INSTALLATION - OVERHEAD DOORS
5128 INSTRUMENT INSTALLATION OR REPAIR
5140 ELECTRICAL WIRING - HIGH WAGE
5146 CABINET OR FIXTURES - INSTALLATION
5160 ELEVATOR ERECTION OR REPAIR
5183 PLUMBING - LOW WAGE
5184 STEAM PIPE OR BOILER INSULATION
5185 AUTOMATIC SPRINKLER INSTALL - LOW WAGE
5186 AUTOMATIC SPRINKLER INSTALL - HIGH WAGE
5187 PLUMBING - HIGH WAGE
5190 ELECTRICAL WIRING - LOW WAGE
5191 OFFICE MACHINE INSTALLATION OR REPAIR
5192 VENDING OR COIN OPERATED MACHINES
5195 COMMUNICATIONS CABLING
5201 CONCRETE WORK - SIDEWALKS - LOW WAGE
5205 CONCRETE WORK - SIDEWALKS - HIGH WAGE
5212 CONCRETE PUMPING
5213 CONCRETE CONSTRUCTION
5214 CONCRETE OR CEMENT WORK
5222 CONCRETE CONSTRUCTION - BRIDGES
5225 REINFORCING STEEL INSTALLATION
5348 TILE, STONE, MOSAIC OR TERRAZZO WORK
5403 CARPENTRY - NOC - LOW WAGE
5432 CARPENTRY - NOC - HIGH WAGE
5436 HARDWOOD FLOOR LAYING
5443 LATHING
5446 WALLBOARD APPLICATION - LOW WAGE
5447 WALLBOARD APPLICATION - HIGH WAGE
5467 GLAZIERS - AWAY FROM SHOP - LOW WAGE
5470 GLAZIERS - AWAY FROM SHOP - HIGH WAGE
5473 ASBESTOS ABATEMENT
5474 PAINTING OR DECORATING - LOW WAGE
5479 INSULATION WORK
5482 PAINTING OR DECORATING - HIGH WAGE
5484 PLASTERING OR STUCCO WORK - LOW WAGE
5485 PLASTERING OR STUCCO WORK - HIGH WAGE
5506 STREET OR ROAD CONSTRUCTION - PAVING
5507 STREET OR ROAD CONSTRUCTION - GRADING
5538 SHEET METAL WORK - ERECTION - LOW WAGE
5542 SHEET METAL WORK - ERECTION - HIGH WAGE
5552 ROOFING - LOW WAGE
5553 ROOFING - HIGH WAGE
5606 CONTRACTORS - EXECUTIVE SUPERVISORS
5610 CONTRACTORS – CONSTRUCTION SUBCONTRACTED
5632 STEEL FRAMING - COMMERCIAL - LOW WAGE
5633 STEEL FRAMING - COMMERCIAL - HIGH WAGE
5650 TERMITE CONTROL WORK
5951 SERUM, ANTI-TOXIN OR VIRUS MFG
6003 PILE DRIVING
6011 DAM CONSTRUCTION
6204 DRILLING
6206 OIL/GAS WELLS - CEMENTING
6213 OIL/GAS WELLS - SPECIALTY TOOL COMPANIES
6216 OIL/GAS LEASE WORK
6218 EXCAVATION - LOW WAGE
6220 EXCAVATION - HIGH WAGE
6233 OIL/ GAS PIPE LINE CONSTRUCTION
6235 OIL/GAS WELLS DRILLING OR RE-DRILLING
6237 OIL/GAS WELLS - WIRELINE SERVICE
6251 TUNNELING
6258 FOUNDATION PREPARATION WORK
6307 SEWER CONSTRUCTION - LOW WAGE
6308 SEWER CONSTRUCTION - HIGH WAGE
6315 WATER MAINS CONSTRUCTION - LOW WAGE
6316 WATER MAINS CONSTRUCTION - HIGH WAGE
6325 CONDUIT CONSTRUCTION
6361 CANAL CONSTRUCTION
6364 IRRIGATION PIPE INSTALLATION
6400 FENCE CONSTRUCTION
6504 FOOD PRODUCTS MFG OR PROCESSING
6834 BOAT BUILDING OR REPAIRING
7133 RAILROADS OPERATION AND MAINTENANCE
7198 PARCEL DELIVERY COMPANIES
7207 STABLES
7219 TRUCKING FIRMS
7227 AUTO TOWING AND ROADSIDE ASSISTANCE
7232 MAIL DELIVERY SERVICE - USPS CONTRACT
7248 MARINE SURVEYORS OR APPRAISERS
7272 WATER TRUCK SERVICE COMPANIES
7332 AMBULANCE SERVICES
7360 FREIGHT HANDLERS
7365 TAXICAB OPERATIONS
7382 BUS OR LIMOUSINE OPERATIONS
7392 BEER OR ALE DEALERS - WHOLESALE
7403 AIRCRAFT OP - SCHEDULED - ALL OTHERS
7405 AIRCRAFT OP - SCHEDULED - FLYING CREW
7409 AIRCRAFT OP - AGRICULTURAL - FLYING CREW
7410 AIRCRAFT OP - AGRICULTURAL - ALL OTHERS
7421 AIRCRAFT OP - PERSONNEL TRANSPORT
7424 AIRCRAFT OP - FLYING CREW
7428 AIRCRAFT OP - NOT AGRI OR SCHEDULED
7429 AIRPORT OPERATORS
7500 GAS WORKS
7515 OIL/GAS PIPE LINE OPERATION
7520 WATERWORKS - OPERATION
7538 ELECTRIC LIGHT OR POWER LINE CONSTR
7539 ELECTRIC LIGHT OR POWER COMPANIES
7580 SANITARY OR SANITATION DISTRICT
7600 TELECOMMUNICATIONS COMPANIES
7601 TELEPHONE OR TELEGRAPH LINE CONSTRUCTION
7605 BURGLAR ALARM INSTALLATION
7606 CABLE TELEVISION COMPANIES
7607 VIDEO POST PRODUCTION
7610 RADIO TELEVISION BROADCASTING STATION
7706 FIREMEN - NOT VOLUNTEERS
7707 FIREMEN - VOLUNTEERS
7720 POLICE - NOT VOLUNTEER
7721 DETECTIVE OR PATROL AGENCIES
7722 POLICE - VOLUNTEER
7855 RAILROAD CONSTRUCTION - ALL OPERATIONS
8001 STORES - FLORISTS
8004 STORES - GARDEN SUPPLIES
8006 STORES - GROCERIES - RETAIL
8008 STORES - CLOTHING AND DRY GOODS - RETAIL
8013 STORES - JEWELRY
8015 STORES - FURNITURE
8017 STORES - RETAIL
8018 STORES - WHOLESALE
8019 PRINTING - QUICK PRINTING
8021 STORES - MEAT/FISH/POULTRY - WHOLESALE
8028 EQUIPMENT OR MACHINERY RENTAL YARDS
8031 STORES - MEAT, FISH OR POULTRY - RETAIL
8032 STORES - CLOTHING, DRY GOODS - WHOLESALE
8039 STORES - DEPARTMENT STORES - RETAIL
8041 STORES - WINE OR SPIRITS - WHOLESALE
8042 STORES - FLOOR COVERINGS
8046 STORES - AUTOMOBILE ACCESSORIES
8057 BOAT DEALERS
8059 STORES - CERAMIC TILE
8060 STORES - WINE, BEER OR SPIRITS - RETAIL
8061 STORES - GROCERIES - CONVENIENCE
8062 STORES - COMPUTERS
8063 STORES - LIGHTING FIXTURES
8064 STORES - OFFICE SUPPLIES AND STATIONERY
8065 STORES - PAINT
8066 STORES - BICYCLES
8070 STORES - VIDEO - RENTAL/SALE - RETAIL
8071 STORES - BOOKS - RETAIL
8078 SANDWICH SHOPS - NOT RESTAURANTS
8102 SEED MERCHANTS
8106 IRON OR STEEL MERCHANTS
8107 MACHINERY DEALERS
8110 STORES - WELDING SUPPLIES
8111 PLUMBERS' SUPPLIES DEALERS - WHOLESALE
8116 FARM MACHINERY DEALERS
8117 STORES - FEED/TACK/FARM SUPPLIES
8209 VEGETABLE AND TOMATO PACKING - FRESH
8215 HAY GRAIN OR FEED DEALERS
8227 CONSTRUCTION OR ERECTION PERMANENT YARDS
8232 LUMBERYARDS - COMMERCIAL
8264 PAPER STOCK DEALERS - SECONDHAND
8265 IRON OR STEEL SCRAP DEALERS
8267 MACHINERY OR EQUIP DEALERS - SECONDHAND
8278 RACING STABLES - JOCKEYS
8286 LIVESTOCK DEALERS/COMMISSION MERCHANTS
8290 WAREHOUSES - SELF STORAGE
8291 WAREHOUSES - COLD STORAGE
8292 WAREHOUSES - GENERAL MERCHANDISE
8293 WAREHOUSES - FURNITURE
8304 GRAIN ELEVATORS OR STORAGE WAREHOUSES
8324 AUTOMOBILE GASOLINE STATIONS
8350 GASOLINE OR OIL DEALERS - WHOLESALE
8387 AUTO OR AUTO TRUCK SERVICE STATIONS
8388 RUBBER TIRE DEALERS
8389 AUTO OR AUTO TRUCK REPAIR SHOPS
8390 AUTOMOBILE VAN CONVERSION OR CUSTOMIZING
8391 AUTO OR AUTO TRUCK DEALER
8392 AUTO OR AUTO TRUCK STORAGE OR PARKING
8393 AUTO-BODY, FENDER REPAIR AND PAINTING
8397 AUTO-TRANSMISSION REPAIR AND REBUILDING
8400 MOTORCYCLE DEALERS
8500 METAL SCRAP DEALERS
8601 ENGINEERS - CONSULTING
8631 RACING STABLES
8720 INSPECTION FOR INSURANCE OR VALUATION
8729 ELEVATOR SERVICE - NO REPAIR
8740 APARTMENT OR CONDOMINIUM COMPLEX OPERATION - PROPERTY MANAGEMENT SUPERVISORS
8741 REAL ESTATE AGENCIES
8742 SALESPERSONS - OUTSIDE
8743 MORTGAGE BROKERS
8745 NEWS AGENT OR DISTRIBUTOR OF MAGAZINES
8748 AUTO OR AUTO TRUCK SALESPERSONS
8749 MORTGAGE BANKERS
8755 LABOR UNIONS
8800 MAILING OR ADDRESSING COMPANIES
8801 CREDIT UNIONS
8803 AUDITORS OR ACCOUNTANTS
8804 ALCOHOLIC AND DRUG RECOVERY HOMES
8806 SHELTERED WORKSHOPS
8807 NEWSPAPER, MAGAZINE OR BOOK PUBLISHING
8808 BANKS
8810 CLERICAL OFFICE EMPLOYEES
8813 PRINTING OPERATION - EDITING
8818 NEWSPAPER PUBLISHING - EDITING
8820 ATTORNEYS
8821 ATTORNEY SUPPORT SERVICES
8822 INSURANCE COMPANIES
8823 RESIDENTIAL CARE FACILITIES - CHILDREN
8827 HOMEMAKER SERVICES
8829 NURSING HOMES
8830 INSTITUTIONAL EMPLOYEES
8831 HOSPITALS - VETERINARY
8834 PHYSICIANS
8838 MUSEUMS
8839 DENTISTS AND DENTAL SURGEONS
8840 CHURCHES - CLERGY
8846 PRINTING OPERATION - SCREEN - EDITING
8847 BEVERAGE CONTAINER COLLECTION OR REDEMPTION
8850 CHECK CASHERS
8851 CONGREGATE LIVING FACILITIES - ELDERLY
8852 HOME INFUSION THERAPISTS
8859 COMPUTER PROGRAMMING OR SOFTWARE DEVELOPMENT
8868 COLLEGES OR SCHOOLS - PRIVATE - PROFESSIONALS
8875 PUBLIC COLLEGES OR SCHOOLS
9007 APT/CONDO OPERATION FOR SENIORS
9008 JANITORIAL SERVICES - BY CONTRACTOR
9009 BUILDING OPERATION - COMMERCIAL
9010 MOBILEHOME PARK OPERATION - ALL OTHER EMPLOYEES
9011 APARTMENT OR CONDOMINIUM COMPLEX OPERATION - ALL OTHER EMPLOYEES
9015 BUILDING OPERATION
9016 AMUSEMENT PARKS OR EXHIBITIONS - MAINTENANCE OF PREMISES
9031 PEST CONTROL
9033 HOUSING AUTHORITIES
9043 HOSPITALS
9048 CAMPS - RECREATIONAL OR EDUCATIONAL
9050 HOTELS
9053 BATHS
9059 DAY CARE CENTERS - CHILD
9060 CLUBS - COUNTRY OR GOLF
9061 CLUBS
9066 HOMEOWNERS ASSOCIATIONS
9067 YMCA OR YWCA INSTITUTIONS
9069 CLUBS - GAMING
9070 RESIDENTIAL CARE FACILITY - ELDERLY
9079 RESTAURANTS OR TAVERNS
9085 RESIDENT CARE - DEVELOPMENTALLY DISABLED
9092 BOWLING CENTERS
9095 EVENT MARKET, FESTIVAL OR TRADE SHOW OPERATION
9096 RESIDENTIAL CLEANING SERVICES
9097 SWIMMING POOL CLEANING AND SERVICING
9101 COLLEGES OR SCHOOLS - PRIVATE - OTHERS
9151 THEATERS - MUSIC ENSEMBLES
9154 THEATERS - NOT MOTION PICTURE
9155 THEATERS - MOTION PICTURE
9156 THEATERS - DANCE/OPERA/THEATER COMPANIES
9180 AMUSEMENT PARKS OR EXHIBITIONS - MAINTENANCE OF DEVICES
9181 ATHLETIC TEAMS OR PARKS
9182 ATHLETIC TEAMS OR PARKS - MAINTENANCE
9184 SKI RESORTS - ALPINE
9185 CARNIVALS OR CIRCUSES
9220 CEMETERY OPERATION
9402 SEWER OR TANK CLEANING
9403 GARBAGE, ASHES OR REFUSE COLLECTING
9410 MUNICIPAL/STATE/PUBLIC AGENCY EMPLOYEES
9420 MUNICIPAL/STATE/PUBLIC AGENCY OTHERS
9422 ROAD DISTRICTS OR DEPARTMENTS
9424 GARBAGE, ASHES OR REFUSE DUMP OPERATIONS
9426 SANITARY COMPANIES
9501 PAINTING - SHOP ONLY
9507 SIGN PAINTING OR LETTERING
9516 TELEVISION, VIDEO, AUDIO AND RADIO EQUIPMENT - INSTALLATION, SERVICE OR REPAIR
9519 HOUSEHOLD APPLIANCES - INSTALLATION
9521 HOUSE FURNISHINGS - INSTALLATION
9522 UPHOLSTERING
9529 SCAFFOLDS, SHORING, DISTRIBUTING TOWERS
9549 ADVERTISING COMPANIES - OUTDOOR
9552 SIGN ERECTION OR REPAIR
9586 BARBER SHOPS OR BEAUTY PARLORS
9610 MOTION PICTURES - PRODUCTION
9620 FUNERAL DIRECTORS
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.
Safety Program Information
Mark box to indicate "Yes".
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.
Glasses, Goggles, Face Shield, Hard Hat, Ear Plugs, Ear Muffs , Dust Mask, Cartage, Auxiliary Air Supply, Steel Toed, Slip Resistant, Rubber Sole
Worksite Evaluation
Please indicate your impressions after a walk through of work site.
Are aisles and passageways clear?
Satisfactory
Unsatisfactory
N/A
Are work areas clean and orderly?
Satisfactory
Unsatisfactory
N/A
Are building exits adequately marked?
Satisfactory
Unsatisfactory
N/A
Are exits free of obstruction?
Satisfactory
Unsatisfactory
N/A
Proper storage of supplies and materials?
Satisfactory
Unsatisfactory
N/A
Adequate ventilation?
Satisfactory
Unsatisfactory
N/A
Are fire evacuation and emergency plans posted?
Satisfactory
Unsatisfactory
N/A
Are portable fire extinguishers accessible?
Satisfactory
Unsatisfactory
N/A
Are fire extinguisher locations clearly designated?
Satisfactory
Unsatisfactory
N/A
Required Notices Displayed
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
Applicable CalOSHA poster
https://www.osha.gov/Publications/osha3165-8514.pdf
Yes
No
CA Minimum Wage
http://www.dir.ca.gov/iwc/MW-2017.pdf
Yes
No
Federal Minimum Wage
https://www.dol.gov/whd/regs/compliance/posters/minwagep.pdf
Yes
No
Payday Notice
http://www.dir.ca.gov/dlse/PaydayNotice.pdf
Yes
No
Safety and health protection on the job
http://www.dir.ca.gov/dosh/dosh_publications/shpstreng012000.pdf
Yes
No
Emergency phone numbers
http://www.dir.ca.gov/dosh/dosh_publications/s500pstr.pdf
Yes
No
Notice to employees - workers' compensation
http://www.edd.ca.gov/pdf_pub_ctr/de1857a.pdf
Yes
No
Notice to employees unemployment insurance benefit
http://www.edd.ca.gov/pdf_pub_ctr/de1857d.pdf
Yes
No
Whistleblower protections
http://www.dir.ca.gov/dlse/WhistleblowersNotice.pdf
Yes
No
Discrimination and harassment in employment
https://www.dfeh.ca.gov/wp-content/uploads/sites/32/2017/06/DFEH_WorkPlaceDiscriminationHarassmentPoster-1.pdf
Yes
No
Pregnancy disability leave
https://www.dfeh.ca.gov/wp-content/uploads/sites/32/2017/06/DFEH-100-20rv201604.pdf
Yes
No
Family care and medical leave
https://www.dfeh.ca.gov/wp-content/uploads/sites/32/2017/06/CFRA_PregnancyLeave_English.pdf
Yes
No
Time off work to vote
http://leginfo.legislature.ca.gov/faces/codes_displaySection.xhtml?lawCode=ELEC§ionNum=14000
.
Yes
No
Federal EEO and ADA
https://www.eeoc.gov/employers/upload/eeoc_self_print_poster.pdf
Yes
No
Federal polygraph protection notice
https://www.dol.gov/whd/regs/compliance/posters/eppabw.pdf
Yes
No
Federal USERRA rights
https://www.dol.gov/vets/programs/userra/USERRA_Federal.pdf
Yes
No
Concluding Information
Does this worksite appear to be a safe place for our employees to work?
Uploads
e.g.Employer Application, Internship Program, Documents (Forms, trainings, presentations, etc) Multiple files can be attached.
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