Please provide the following personal contact information:

Student Name
Street Address
Address (cont.)
City
State/Province
Zip/Postal Code
Country
E-mail
Home Phone
Current Date
Co-op Semester	. . . Fall Spring Summer
Co-op Year	. . . 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015

Please provide the following employer contact information:

Supervisor's Name
Company/Organization
Employer Phone
Employer E-mail

Assessment of Your Skills.  In order to provide a baseline profile at the completion of  your work-based learning experience, we would like you to assess your competencies and performance for the following set of skills. Base your assessments on the skill levels of your coworkers at the organization.

Assessment scale:  0 to 10   

      0 = Lacks skill     

      2 = Minimal skill level 

      5 = Average     

      7 = Above average     

    10 = Exceptional         

   n/a = Not Applicable

Communication                                      

Oral (speaking and listening)  ...... 0 1 2 3 4 5 6 7 8 9 10 n/a

Written (clear, accurate, informative) ...... 0 1 2 3 4 5 6 7 8 9 10 n/a

Client/customer oriented, friendly, polite ...... 0 1 2 3 4 5 6 7 8 9 10 n/a

Self Management

Judgment, makes sound decisions ...... 0 1 2 3 4 5 6 7 8 9 10 n/a

Detail oriented, accurate, thorough ...... 0 1 2 3 4 5 6 7 8 9 10 n/a

Performs under pressure, adaptable, flexible ...... 0 1 2 3 4 5 6 7 8 9 10 n/a

Resolves conflicts ...... 0 1 2 3 4 5 6 7 8 9 10 n/a

Punctual, dependable, uses time efficiently ...... 0 1 2 3 4 5 6 7 8 9 10 n/a

Works independently without supervision ...... 0 1 2 3 4 5 6 7 8 9 10 n/a

Teamwork

Teamwork, rapport with co-worker, interpersonal ...... 0 1 2 3 4 5 6 7 8 9 10 n/a

Organizes and plans ...... 0 1 2 3 4 5 6 7 8 9 10 n/a

Respects others, accepts criticism, tactful ...... 0 1 2 3 4 5 6 7 8 9 10 n/a

Appropriate leadership/follower relationship ...... 0 1 2 3 4 5 6 7 8 9 10 n/a

Problem Solving/Decision Making

Creative, offers new perspectives ...... 0 1 2 3 4 5 6 7 8 9 10 n/a

Analytical ability ...... 0 1 2 3 4 5 6 7 8 9 10 n/a

Initiative

Self-confident, decisive ...... 0 1 2 3 4 5 6 7 8 9 10 n/a

Completes work despite obstacles, persistent ...... 0 1 2 3 4 5 6 7 8 9 10 n/a

Seeks opportunities to learn, puts in extra effort ...... 0 1 2 3 4 5 6 7 8 9 10 n/a

Technical/Professional

Technical (hardware, software) ...... 0 1 2 3 4 5 6 7 8 9 10 n/a

Applies organization's technology effectively ...... 0 1 2 3 4 5 6 7 8 9 10 n/a

Understands and applies knowledge/theory ...... 0 1 2 3 4 5 6 7 8 9 10 n/a

Professional attitude and appearance ...... 0 1 2 3 4 5 6 7 8 9 10 n/a

Honest, ethical, has integrity ...... 0 1 2 3 4 5 6 7 8 9 10 n/a

Comments:

 

Part 2

Assessment scale:  0 to 10 

      0 = LOW     (Inadequate  / none to little)

      5 = MIDDLE     (Sufficient  / some)

    10 = HIGH      (Very Thorough  / great)

My prior academic coursework prepared me for this learning experience.  . . . 1 2 3 4 5 6 7 8 9 10

My prior work experience prepared me for this learning experience. . . . 1 2 3 4 5 6 7 8 9 10

The orientation provided by my site supervisor was: ...... 0 1 2 3 4 5 6 7 8 9 10  

My Learning Agreement's contribution to overall value of this experience .... 0 1 2 3 4 5 6 7 8 9 10  

Job responsibilities assigned by my site supervisor were .... 0 1 2 3 4 5 6 7 8 9 10  

Overall educational value of this experience .... 0 1 2 3 4 5 6 7 8 9 10  

My overall performance .... 0 1 2 3 4 5 6 7 8 9 10  

My duties included 

This Term's work period extended from

. . . January February March April May June July August September October November December . . . 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 . . . 2006 2007 2008 2009 2010 to  . . . January February March April May June July August September October November December . . . 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 . . . 2006 2007 2008 2009 2010

This experience was: Unpaid Paid

If paid, at what rate?  $/hours

Hours worked per week            X            Number of weeks =          Total hours

Please give suggestions for improving the quality of Cooperative Education experiences. (Recommendations for employers, faculty, Career Center staff, other students, etc.)

What effect has this experience had on defining or focusing your career goals?

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