To be completed near the beginning of your Cooperative Education experience. A copy of this completed form will be sent to your faculty coordinator and employer supervisor.
Please provide the following personal contact information:
Student Name Student 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
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