Fillable Internship Approval Form (California State University, Chico)

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Internship Approval Form (California State University, Chico)

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The Internship Approval Form (California State University, Chico) form is 3 pages long and contains:

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  • 14 check-boxes
  • 37 other fields

Country of origin: US
File type: PDF

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California State University, Chico
Department of Mechanical and Mechatronic Engineering and Sustainable Manufacturing
Last updated 2019-03-12
Industrial Internship Approval
☐
☐
☐
Mechanical Engineering – MECH 389
Mechatronic Engineering – MECA 389
Sustainable Manufacturing – SMFG 389
Term:
Year:
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
student intern.
Yes ☐ No ☐ N/A ☐
California State University, Chico
Department of Mechanical and Mechatronic Engineering and Sustainable Manufacturing
Last updated 2019-03-12
Section III: Learning Objectives
Identify three measurable 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. Note that
the objectives may be modified during the course of the internship based on employer needs.
Learning Objective 1:
Le
arning Objective 2:
Le
arning Objective 3:
Section IV: Approvals
Student:
Signature:
Date:
Supervisor:
Signature:
Date:
Instructor:
Signature:
Date:
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California State University, Chico
Department of Mechanical and Mechatronic Engineering and Sustainable Manufacturing
Last updated 2019-03-12
Section V: Site Assessment
Th
is 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 provide 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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signature
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Internship Approval Form (California State University, Chico)

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Completed 18 July 2020

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