Fillable WORK-BASED LEARNING (CO-OP) APPLICATION (Sandhills Community College)

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WORK-BASED LEARNING (CO-OP) APPLICATION (Sandhills Community College)

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The WORK-BASED LEARNING (CO-OP) APPLICATION (Sandhills Community College) form is 7 pages long and contains:

  • 15 signatures
  • 8 check-boxes
  • 317 other fields

Country of origin: US
File type: PDF

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Sandhills Community College WBL Form 1
WORK-BASED LEARNING (CO-OP) APPLICATION
SECTION 1 – TO BE COMPLETED BY THE STUDENT
Student Name: Student ID#:
Address:
E-mail: Phone#:
Are you 18 years of age or older? YES □ NO □
Program: Degree □ Diploma □ Certificate □
Student Signature:
SECTION 2 – TO BE COMPLETED BY THE ADVISOR / WBL FACULTY COORDINATOR
Semester: Course:
Section:
Credit Hours:
I verify that the student meets the eligibility requirements and has my recommendation to participate in co-op.
Faculty Coordinator: Date:
Forms 1-4 must be submitted for verification
within 2 days of the semester census date
ADMINISTRATIVE
VERIFICATION
□ Correct Program
□ Registered in Datatel
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Sandhills Community College WBL Form 2
WORK-BASED LEARNING (CO-OP) AGREEMENT
Student Name
Program
Employer
Semester
Employer Address
Hours Required
Supervisor
Supervisor Phone
Supervisor Email
Sandhills Community College and the cooperating employer/agency agree to observe placement procedures and employment
practices which conform to all federal, state, and local laws and regulations (including nondiscrimination toward any participant or
employee because of race, color, religion, sex, veteran's status, disability, or national origin). The following statements constitute
the Agreement on which participation in the Work-Based Learning Program at Sandhills Community College is based:
College Responsibilities
1. Provide consultation and coordination among the student, the employer, and the college.
2. Determine if the worksite is appropriate and conducive to the participant’s learning.
3. Review and approve the job description or learning objectives.
4. Conduct on-site visits with students and their immediate supervisors.
5. Determine a grade for the work experience and award college credit based on the student's performance.
Employer Responsibilities
1. Provide at least the minimum hours of employment as indicated above.
2. Compensate student at a level consistent with regular employees in a similar training situation.
3. Identify a qualified employee to serve as the immediate supervisor, who will mentor the student and will complete all required
forms, including the student’s time sheet and evaluation.
4. Permit on-site visits by a College representative.
5. Notify the College of any issues or concerns regarding the student.
6. Provide Workers’ Compensation liability Insurance as applicable according to state law.
7. Give permission to use employer's name in WBL marketing/promotional materials.
8. Adhere to the Fair Labor Standards Act. Assure a safe and healthy work environment.
9. Encourage the student to continue his/her higher education to completion.
Student Responsibilities
1. Report punctually and regularly for work. Notify the employer promptly if you are unable to work for any reason.
2. Adhere, at all times, to the employer's work rules and regulations.
3. Meet with your supervisor within the first week to review the job description or develop learning objectives that align with your
program of study.
4. Inform the college's Financial Aid Office of the student’s WBL employment and report wages earned during the work
experience, if appropriate. Understand that federal and state law prohibits a student from collecting unemployment benefits
after a paid WBL work experience has ended.
Statement of Cooperation
I have read, fully understand, and agree to abide by the responsibilities stated in this Agreement, and I will strive to make this a
successful learning experience.
Student Signature Date Employer Signature Date
Faculty Coordinator Signature Date
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Sandhills Community College WBL Form 3
WORK-BASED LEARNING (CO-OP) ACTIVITY REPORT
Student Name: Program:
Semester:
Work Start Date:
MON
TUE
WED
THUR
FRI
SAT
SUN
Dates
Time
Total
hours
Row Total
I verify this is a true and accurate account of hours worked.
Student Signature: _________________________________________ Date: _________________
Supervisor Signature: _______________________________________ Date: _________________
If the student’s work hours will not begin until after the semester census date, a one-hour orientation may be
substituted to confirm student activity.
Orientation Date:
Student Signature: _________________________________________ Date: _________________
Faculty Signature: _________________________________________ Date: _________________
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Sandhills Community College WBL Form 4
WORK-BASED LEARNING (CO-OP) JOB DESCRIPTION/LEARNING OBJECTIVES
The job description OR learning objectives must align with your program of study and should clearly describe what you
intend to accomplish during your WBL work term. They will be reviewed by your supervisor, who may suggest changes or
additions within the first two weeks of the term, and approved by your WBL instructor.
If you are currently working for your WBL employer, your objectives must include learning new skills or levels of skills
beyond what was demonstrated in a previous WBL or job training.
JOB DESCRIPTION: (may be attached to the Agreement in lieu of this form)
LEARNING OBJECTIVES:
By the end of the term, I will accomplish the following objectives as rated by my supervisor:
1.
2.
3.
4.
Student Signature Date
I agree with the validity of these objectives and believe they can be reasonable accomplished in the hours required for
the student.
Supervisor Signature Date
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Sandhills Community College WBL Form 5
WORK BASED-LEARNING (CO-OP) EMPLOYER CONSULTATION
Student
Name
Semester
Program
□ On site □ Telephone □ Other (specify)
Date of Consultation:
Student’s performance at this time:
Unsatisfactory
Satisfactory
Exceptional
Knowledge of subject
Relations with coworkers
Attitude toward work
Reaction to supervision
Quality of work
Punctuality
OVERALL PERFORMANCE
Comments:
Supervisor Signature Faculty Coordinator Signature
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Sandhills Community College WBL Form 6
WORK-BASED LEARNING EMPLOYER’S EVALUATION
Student Name: Semester: _
Program ______________________________________
Please place a check mark in the space beside the best description of the student’s performance in each category below.
Please evaluate the student objectively, comparing him/her with other students of comparable academic level or
similarly classified jobs.
RELATIONS WITH OTHERS
_____ Exceptionally well accepted
_____ Works well with others
_____ Gets along satisfactorily
_____ Some difficulty working with others
_____ Works very poorly with others
ATTITUDE TOWARD WORK
_____ Outstanding enthusiasm
_____ Very interested and industrious
_____ Average in diligence and interest
_____ Somewhat indifferent
_____ Definitely not interested
JUDGEMENT
_____ Exceptionally mature
_____ Above average in making decisions
_____ Usually makes the right decision
_____ Often uses poor judgment
_____ Consistently uses poor judgment
DEPENDABILITY
_____ Completely dependable
_____ Above average in dependability
_____ Usually dependable
_____ Sometimes neglectful or careless
_____ Unreliable
ABILITY TO LEARN
_____ Learns very quickly
_____ Learns readily
_____ Average in learning
_____ Rather slow to learn
_____ Very slow to learn
QUALITY OF WORK
_____ Excellent
_____ Very good
_____ Average
_____ Below average
_____ Very poor
ATTENDANCE
_____ Regular
_____ Irregular
PUNCTUALITY
_____ Regular
_____ Irregular
OVERALL PERFORMANCE
_____ Excellent
_____ Very good
_____ Average
_____ Below average
_____ Very poor
Comments:
____________________________________________________________________________________________
____________________________________________________________________________________________
Supervisor’s Signature Date
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Sandhills Community College WBL Form 7
WORK-BASED LEARNING (CO-OP) TIME REPORT
Student Name
Semester
Program
Hours Required
Please list clock hours and sum at the end of the week; ex. 4:30pm-6:00 PM
The supervisor’s signature must not be dated prior to work listed on this timesheet.
Week of:
Hours
Total Hours
for the Week
Supervisor’s
Initials
Monday Date:
Week#
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday
SAMPLE:
May 23, 2020
1 2:00-05:00 2:00-7:00 8 THD
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
Extra
Total Hours:
I verify this is a true and accurate of hours worked.
Student Signature_________________________________________ DATE_________________
I approve this statement of work hours.
Supervisor Signature______________________________________ DATE_________________
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WORK-BASED LEARNING (CO-OP) APPLICATION (Sandhills Community College)

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Completed 3 February 2021

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