CUSTOMIZED LEARNING PLAN AND EMPLOYER EVALUATION Circle the Term Student was Registered: Fall
Spring
Summer
Fall
Spring
Summer
2012-10
2012-20
2012-30
2013-10
2013-20
2013-30
DIRECTIONS TO THE STUDENT: Complete this section and Student Section of Major Learning Objectives below. Student’s Name Faculty Name Std Home Phone Std Alternate Phone Employer Name
Faculty Phone/ Faculty Fax No. Intern Job Title
Site Supervisor/ Supervisor Phone One year educational/employment/career goals: 1.
Total Hours Required of Internship
2.
2.
Three-year educational/employment/career goals: 1.
Rating of Job Requirements/Internship Goals Rating Excellent (E) Very Good (VG) Good (G) Fair (F) Poor (P)
DIRECTIONS TO THE EMPLOYER: Please use the scoring system at right to rate the student’s job performance.
Point Value 5 pts 4 pts 3 pts 2 pts 1 pt
How to Determine Always Exceed Job Requirements Sometimes Exceeds Job Requirements Meets Job Requirements Sometimes Meets Job Requirements Rarely Meets Job Requirements
PERFORMANCE RATING (Completed by the Employer) E (5) VG(4) G(3) F(2) P(1)
MAJOR LEARNING OBJECTIVES PROGRAM OBJECTIVES -- (Developed by FIS) 1. 2. 3. 4.
EMPLOYER OBJECTIVES -- (Developed by Employer re: Specific duties assigned to this Student.) 1. 2. 3. 4.
STUDENT OBJECTIVES — (Developed by Student with FIS) 1. 2. 3. 4. Subtotal Score for this Page (5) CLP.v08.11
WORKPLACE SKILLS 1.
Adaptability
2.
Appearance
3.
Ask questions to clarify expectations/instructions
4.
Attendance
5.
Communication skills
6.
Critical thinking
7.
Follow directions appropriately
8.
Follow safety procedures/precautions
9.
Initiative
10.
Interest in work
11.
Interpersonal skills
12.
Quality of work
13.
Quantity of work
14.
Teamwork
E(5)
PERFORMANCE RATING (Completed by Employer) VG(4) G(3) F(2) P(1)
Subtotal Score for This Page Subtotal Score from First Page
TOTAL POINTS HOW MANY HOURS DID THE STUDENT COMPLETE WITH YOUR COMPANY?
EMPLOYER’S COMMENTS: 1. What skills/qualities did the student demonstrate during the internship that enhanced the performance of his/her job?
2. What does the student need to do to improve his/her marketable skills in order to compete for positions in this industry?
EMPLOYER’S SIGNATURE/TITLE
DATE
NAME OF COMPANY
INDUSTRY TYPE (Ex: Computer Related, Education, Finance, Government, Health Related, Hospitality/Tourism, Radio/TV, Soc. Sciences, etc.)
Fax this completed form to the Faculty Internship Supervisor at ____________________. (6)
CLP.v08.11
FACULTY SUPERVISOR’S COMMENTS:
FACULTY SUPERVISOR’S SIGNATURE
DATE
(7) CLP.v08.11