Sandhills Community College WCE WBL FORM 1 Rev. 2020
WORKFORCE CONTINUING EDUCATION (WCE)
WORK BASED LEARNING (WBL) APPLICATION
SECTION 1 TO BE COMPLETED BY THE STUDENT
Student Name: Student ID#:
Phone#:
NO
Address:
E-mail:
Are you 18 years of age or older? YES
Program:
Student Signature:
SECTION 2 TO BE COMPLETED BY THE WCE WBL STAFF DESIGNEE
Semester:
Course No. :
Linked Course No.:
Class Hours:
I verify that the student meets the eligibility requirements and has my recommendation to participate in WBL.
Program Coordinator: Date:
Forms 1-4 must be submitted for verification
within 2 days of the semester census date
ADMINISTRATIVE
VERIFICATION
Correct Class
Registered in Datatel
Sandhills Community College WBL FORM 2 Rev. 2020
WORKFORCE CONTINUING EDUCATION (WCE)
WORK BASED LEARNING (WBL) AGREEMENT
Student Name
Employer
Employer Address
Supervisor
Class
Semester
Hours Required
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 through WCE 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 co-op 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 co-op 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 co-op 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
WCE WBL Program Coordinator
Signature
Date
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signature
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signature
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Sandhills Community College WCE WBL FORM 3 Rev. 2020
WORKFORCE CONTINUING EDUCATION (WCE)
WORK BASED LEARNING (WBL)ACTIVITY REPORT
Student Name: WBL Class:
Semester:
Work Start Date:
example
MON
TUE
THUR
FRI
SAT
SUN
Dates
8/18/14
Time
1-4 pm
Total
hours
3
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: _________________
WBL Coordinator Signature: _________________________________________ Date: _________________
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signature
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signature
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signature
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Sandhills Community College WCE WBL FORM 4 Rev. 2020
WORKFORCE CONTINUING EDUCATION (WCE)
WORK BASED LEARNING (WBL) 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/coordinator.
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 experience.
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
Sandhills Community College WCE WBL FORM 5 Rev. 2020
WORKFORCE CONTINUING EDUCATION (WCE)
WORK BASED LEARNING (WBL) EMPLOYER CONSULTATION
Semester
Student Name
Class
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
Sandhills Community College WCE WBL FORM 6 Rev. 2020
WORKFORCE CONTINUING EDUCATION (WCE)
WORK BASED LEARNING (WBL) EMPLOYER’S EVALUATION
Semester
Student Name
WBL Class
Please circle 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
ATTITUDE TOWARD WORK
_____
Exceptionally well accepted
_____
Outstanding enthusiasm
_____
Works well with others
_____
Very interested and industrious
_____
Gets along satisfactorily
_____
Average in diligence and interest
_____
Some difficulty working with others
_____
Somewhat indifferent
_____
Works very poorly with others
_____
Definitely not interested
JUDGMENT
DEPENDABILITY
_____
Exceptionally mature
_____
Completely dependable
_____
Above average in making decisions
_____
Above average in dependability
_____
Usually makes the right decision
_____
Usually dependable
_____
Often uses poor judgment
_____
Sometimes neglectful or careless
_____
Consistently uses poor judgment
_____
Unreliable
ABILITY TO LEARN
QUALITY OF WORK
_____
Learns very quickly
_____
Excellent
_____
Learns readily
_____
Very good
_____
Average in learning
_____
Average
_____
Rather slow to learn
_____
Below average
_____
Very slow to learn
_____
Very poor
ATTENDANCE
OVERALL PERFORMANCE
_____
Regular
_____
Excellent
_____
Irregular
_____
Very good
PUNCTUALITY
_____
Average
_____
Regular
_____
Below average
_____
Irregular
_____
Very poor
Comments:
Supervisor’s Signature Date
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signature
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Sandhills Community College WCE WBL FORM 7 Rev. 20202
WORKFORCE CONTINUING EDUCATION (WCE)
WORK BASED LEARNING (WBL) TIME REPORT
Semester
Student Name
Class
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.
I verify this is a true and accurate of hours worked.
Student Signature_________________________________________ DATE_________________
I approve this statement of work hours.
Supervisor Signature______________________________________ DATE_________________
Week of:
Monday Date Week # Monday Tuesday Wednesday Thursday Friday Saturday Sunday
SAMPLE
May 23, 2011
1 2:00-5:00 2:00-7:00 8 THD
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
Hours
Total Hours:
Total Hours
for the Week
Supervisor's
Initials
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