COOPERATIVE WORK EXPERIENCE EDUCATION LEARNING OBJECTIVE FORM (COOP/CWEE/WRKX)
Student Name: _ Student ID #: _ Course/Section # _
Student Email:
Worksite Name:
Student Phone #: _
Worksite Address: _
Supervisor: Email: _ Phone:
1. Each term that a Student is enrolled in a Work Experience class, it is necessary to identify a minimum of 3 new learning
objectives. Learning objectives that reflect new or expanded job-related responsibilities must be written by the student then
approved by the Employment Supervisor and the Instructor at the beginning of the semester. The objective must be
substantive, measurable, and attainable.
2. The Supervisor will meet with the Instructor at least once during the semester to evaluate the Student’s performance on their
learning objectives. The Instructor will award academic credit for successful completion of the program requirements.
STUDENT LEARNING OBJECTIVES (STUDENT/SUPERVISOR COMPLETE)
Supervisor Score
1
By the end of the semester I will learn and/or improve:
2
By the end of the semester I will learn and/or improve:
_ _
_ _
_ _
3
By the end of the semester I will learn and/or improve:
_ _
_ _
_ _
4
By the end of the semester I will learn and/or improve:
_ _
_ _
Agreement
The three participants in the Work Experience program agree with the validity of the above learning objectives. The Student agrees to abide by the
program requirements. The Employment Supervisor will meet with the Instructor at least once during the semester to evaluate the Student’s
performance on the learning objectives. The Instructor will award academic credit for successful completion of the objectives. The Employment
Supervisor and the Instructor will provide Supervision and guidance to insure maximum educational benefit from this work experience. The Contra
Costa Community College District does not discriminate on the basis of race, national origin, sex, color, religion, age, or disability in employment,
educational programs and activities. Employers who sign this contract are expected to uphold this policy in their selection of prospects for
employment, educational processes, or activities. It is understood that the District will provide Worker’s Compensation for UNPAID Internships
and/or liability insurance as required by law.
Supervisor Signature
Student Signature _
Instructor Signature
Date __
Date _
Date _
Version 1.0 6.3.20
Notes (Optional):
Final Instructor Signature _ Date _______
Yes
Yes
Non-paid Course Hours Total =
Date: ___ 2
nd
Contact Date: _
Date:
Date: _
1st Contact
Contact with Supervisor:
Visitation of work site by instructor:
Personal Consultation(s) with Student
END OF TERM EVALUATION INSTRUCTOR USE ONLY
Course Units: Final Grade: Paid
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