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




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: 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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