COOPERATIVE WORK EXPERIENCE EDUCATION LEARNING OBJECTIVE FORM (COOP/CWEE/WRKX)
Student Name: ___________________________________ Student ID #: ___________ Course/Section # ____________
Student Email: __________________________________ Student Phone #: ________________________________
Worksite Name: _________________________________ 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)
By the end of the semester I will learn and/or improve:
_______________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
By the end of the semester I will learn and/or improve:
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
By the end of the semester I will learn and/or improve:
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
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 ________________________________________ Date ______________________
Student Signature __________________________________________ Date ______________________
Instructor Signature _________________________________________ Date ______________________
END OF TERM EVALUATION – INSTRUCTOR USE ONLY
Course Units: _______ Final Grade: _______ Paid Non-paid
Course Hours Total = ________
Contact with Supervisor: 1st Contact Date: ___________ 2
nd
Contact Date: ___________
Visitation of work site by instructor: Yes No Date: ___________
Personal Consultation(s) with Student Yes No Date: ___________
Notes (Optional): ____________________________________________________________
Final Instructor Signature ___________________________________________ Date _________________________
