Fillable Civl-placement-form-summer19 - CIVL Placement Form

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Civl-placement-form-summer19 - CIVL Placement Form

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File type: PDF

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California)State)University,)Chico)
Department)of)Civil)Engineering))
CIVL)389)Internship)Approval
Return the completed form via e-mail to the Civil Engineering Department Chair
Section I: Student Data
Name: Student ID:
Email: Telephone:
Primary Emergency Contact:
Relation:
Daytime Telephone: Cell Phone:
Secondary Emergency Contact (optional):
Daytime Telephone:
Cell Phone:
Section II: Internship Site
Company Name:
Address: City: State: Zip:
Principal Business:
Supervisor:
Email: Phone:
Expected Start Date: Expected End Date: Estimated total hours:
Is this a paid internship?
Yes
☐ No ☐
The internship site has agreed to accommodate the accessibility needs of the
st
udent intern.
Yes
☐ No ☐ N/A ☐
California)State)University,)Chico)
Department)of)Civil)Engineering))
Section III: Learning Objectives
Identify three measureable Student Learning Objectives (SLOs) for the internship experience. These must be
agreed upon with the supervisor who will be responsible for assessment at the end of the internship.
Learning Objective 1:
Learning Objective 2:
Learning Objective 3:
Section IV: Approvals
Student: Signature: Date:
Supervisor: Signature: Date:
Instructor: Si
gnature: Date:
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California)State)University,)Chico)
Department)of)Civil)Engineering))
Section V: Site Assessment
This section is to be completed by a representative of the internship site. Questions should be directed to the
CSU Chico Office of Risk Management, 530-898-6588, risk@csuchico.edu.
The internship site agrees to provide student intern appropriate and necessary training
for the work environment. This includes health, safety, and emergency procedures. If
No, employer should contact Risk Management.
Yes
☐ No ☐
The internship site agrees to pr
ovide training and personal protective equipment when
student interns work with any hazardous materials or machinery. If No, employer should
contact Risk Management.
Yes
☐ No ☐
Will the student intern work unsupervised with minors?
If Yes, employer should contact
Risk Management.
Yes
☐ No ☐
Name:
Signature:
Title: Date:
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Completed 22 March 2020

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