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.

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

General Internship Information

FCCC Client*
Please select college.

Internship Start Date*

Internship End Date*

College representative*

College Representative Email*

Employer Interviewed*
Employer or Sponsor representative responsible for internship oversite and evaluation.

Worksite / Employer*
Employer/Business/Makerspace/Sponsorship Name

Employer Email*

Worksite Address*
Employer/Business/Makerspace/Sponsorship Location

Work Site Description*
Industry/business/makerspace description

Job Description*
Duties to be performed at worksite.

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

Application*
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.

Worker's Compensation Information

Department

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.

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.

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

Are aisles and passageways clear?