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Revised: November 2014

Alabama Work-Based Learning Manual

A Guide For Work-Based Learning ExperiencesIn Secondary Education

Alabama State Department of EducationCareer and Technical Education

www.alsde.edu

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http://www.alsde.edu/

Alabama State Department of Education

Career and Technical EducationP. O. Box 302101

Montgomery, AL 36130-2101334-242-9111

www.alsde.edu

Alabama State Department of Education, Thomas R. Bice, Ed.D., State Superintendent of Education

The Alabama State Board of Education and the Alabama State Department of Education do not discriminate on the basis of race, color, disability, sex, religion, national origin, or age in its programs, activities, or employment and provide equal access to the Boy Scouts and other designated youth groups. The following person is responsible for handling inquiries regarding the non-discrimination policies: Title IX Coordinator, Alabama State Department of Education, P. O. Box 302101, Montgomery, AL 36130-2101, telephone (334) 242-8165.

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TABLE OF CONTENTS Work-Based Learning Matrix of Experiences ..........................................................4 ...........................................................................................................................................Introduction.....................................................................................................................7

7Cooperative Education ....................................................................................................910Cooperative Education Forms......................................................................................19 23ALSDE Approved National Academy Internships .......................................................4454Health Science Clinical Internship ..............................................................................46

Health Science Clinical Internship Forms ...................................................................49 59Education and Training Internship ...............................................................................5961Education and Training Internship Forms....................................................................62

Supervised Agricultural Experience.............................................................................90 66Health Science Career Shadowing ...............................................................................92 68Health Science Career Shadowing Forms ....................................................................94

School-Based Enterprises ............................................................................................98 72Industry Tours and Job Fairs .....................................................................................100 74Job Shadowing ...........................................................................................................101 75ALSDE Approved Work-Based Learning Pilot Experience ......................................102 76ALSDE Approved Industry-Based Learning Experience ...........................................10478Resources/Contacts ...................................................................................................10680Acknowledgements ...................................................................................................10781Bibliography ..............................................................................................................112

Revision Committee Members....................................................................................113

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Work-Based Learning

Matrix of Experiences

4

Cooperative Education

SDE Approved National Academy

Internships

Health Science Clinical

Internship

Education and

Training Internship

Supervised Agricultural Experience

Health ScienceCareer

Shadowing

School-Based

Enterprises

Industry Tours/Job

Fairs

Job Shadowing

Work-Based

Learning Pilot

Experience

Industry-Based

Internship Experience

Teacher Certification

Class B CTE Certification with Cooperative Education coursework

Approved Academy or Cooperative Education

Health Science

FACS(Excluding Level and Specialty Area Certification)

Agriscience Education (Including Level and Specialty Area Certification)

Health Science or

Science

CTE Certified Teacher





Minimum Number of CTE Credits Successfully Earned Prior to Enrollment & Prerequisites

Career Preparedness

(Or) 1 CT

Course

0 1 2 or 3 0 0 0 0 0

Career Preparedness

(Or) 1 CT

Course

Career Preparedness

(Or) 1 CT

Course

Concurrent Classroom Instruction

Seminar per LEA

decisionNo Yes

Education and Training

InternshipYes Yes Yes No No

Seminar per LEA

decision

Seminar per LEA

decisionRequirement for Determination of Career Objective

Yes No Yes Yes Yes Yes Yes No No Yes Yes

Grade Level 11-12 11-12 11-12 11-12 7-12 9-12 9-12 7-12 7-12 9-12 9-12

Summer School Credit

Yes (if the Coordinator is on an extended contract, and the student is enrolled in summer school.)

No

Yes (If Health Science teacher is on an extended contract, and the student is enrolled in summer school.)

No NA NA NA NA NA

Yes (if the Coordinator

is on an extended

contract, and the student is enrolled in

summer school.)

Yes (if the Coordinator

is on an extended

contract, and the student is enrolled in

summer school.)

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Cooperative Education

ALSDE Approved National Academy

Internships

Health Science Clinical

Internship

Education and

Training Internship

Supervised Agricultural Experience

Health ScienceCareer

Shadowing

School-Based

Enterprises

Industry Tours/Job

Fairs

Job Shadowing

Work-Based

Learning Pilot

Experience

Industry-Based

Internship Experience

Time Requirement for Credit

Successful completion of 140 minimum hours per credit. Averaging 15 hours per week, a majority of these hours should be worked Monday through Friday.

NA

Credit is earned as a part of the Health Science CTE course.

Successful completion of 140 hours. Hours must be worked Monday through Friday during the school day.

NA

Credit is earned as a part of the Health Science CTE course or Project Lead the Way (PLTW) course.

Credit is earned as part of the CTE course.

NA NA

Successful completion

of 140 minimum hours per

credit. Averaging

15 hours per week, a

majority of these hours should be worked Monday through Friday.

Successful completion

of 140 minimum hours per

credit. Averaging

15 hours per week, a

majority of these hours should be worked Monday through Friday.

Coordination/ Supervision Responsibility

CoordinatorCoordinator/

Academy Teacher

Health Science Teacher

FACS Teacher

Agriscience Teacher

Health Science Teacher or Science Teacher (PLTW)




Coordinator Coordinator

Required Plans and Agreements

Training plan and training agreement

As required by the Academy

Clinical Internship Training Agreement, Student Confidenti- ality Statement, and CPR Certification

Education and Training Internship Agreement and Professional Work Sample Portfolio

NA

Career Shadowing Training Agreement and Student Confidentiality Statement

NA No No

Training plan and training

agreement

Training plan and training

agreement

Students Paid for Work

Yes/may be

May be paid No No May be paid No No No No Yes No

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INTRODUCTION

“Research has indicated that work-based experiences invigorate learning and that students participating in work-based learning were more likely to stay in school, take more difficult courses, and graduate.”- Swail, Watson S. and Kampits, Eva, 2004

Work-based learning provides students with educational opportunities that typically cannot be replicated in the classroom. The Carl D. Perkins Career and Technical Education Act of 2006 (Perkins IV) emphasizes the necessity of providing students with strong experiences in, and comprehensive understanding of, all aspects of the industry that the student is preparing to enter. This manual provides a framework for meeting this mandate through rigorous, relevant experiences in the classroom and in a work-based learning setting.

The work-based experiences included in this manual are designed to make learning relevant, improve graduation rates, and better prepare students for careers or continued education and to connect information learned in the classroom with skills obtained in an occupational setting. These experiences include cooperative education, Health Science Clinical Internship, Education and Training Internship, Supervised Agricultural Experience, Health Science Career Shadowing, school-based enterprises, industry tours and job fairs, job shadowing, work-based learning pilot experiences, and industry-based learning experiences.

This manual contains policies, techniques, and procedures to be used for all work-based learning experiences. It provides instruction, guidance, direction, and the documentation necessary to develop and implement a quality, work-based learning experience. Information contained herein should be used as a guide for teachers, counselors, school administrators, and others involved in providing work-based learning experiences.

Benefits of Work-Based LearningWork-based learning is a major component of career and technical education. Improved skills lead to higher efficiency and the availability of a better-trained labor pool that encourages business growth and productivity. Well-managed work-based learning experiences build confidence in the school system and have benefits for the student, employer, mentor, school, and community.

The students may be given the opportunity in work-based learning experiences to: Receive specific school-based and work-based training in a chosen career while attending

high school. Earn income and become financially literate in some experiences. Reinforce and apply academic competencies. Develop, demonstrate, and refine safe work habits. Demonstrate responsibility, maturity, job competency, and decision-making skills. Gain an understanding of the financial operations, employment opportunities, and

organizational structure of business and industry. Develop a portfolio of academic, technological, occupational, and work-readiness skills. Improve the transition from school to work. Participate in Career Technical Student Organizations (CTSOs) related to their career

objectives and coursework.

The employer or the employer-mentor may be given the opportunity to:7

Be involved in the total school program. Participate in the development of a work-based training plan that meets labor market

demands. Create an awareness of training needs for their business and industry. Employ part-time employees that provide more flexible scheduling. Develop positive public relations and build goodwill through partnerships with schools.

The school may be given the opportunity to: Increase the graduation rate. Create broader curricula that encourage students to accomplish their educational goals. Allow flexibility of instruction. Meet the career goals of a diverse student population. Correlate school-based learning with work-based learning. Provide valuable industry contacts and opportunities for partnership development. Enable students to receive training in a number of occupations in state-of-the-art facilities,

utilizing the most current technology with minimal capital expense for the school.

The community may be given the opportunity to: Participate in partnership development with the school system. Increase the local economy with student earnings. Provide awareness of local career opportunities. Assist students in appropriate career selection. Participate as a member of a local CTE Advisory Council/Committee.

COOPERATIVE EDUCATION8

(Changes to the 2012 CIT Work-Based Learning Manual) (Revised: November 2014)

Cooperative Education is a structured component of the Career and Technical Education (CTE) curriculum that integrates classroom instruction with productive, progressive, supervised, work-based experiences/apprenticeships (Paid) and internships (Unpaid), related to students’ career objectives. Content is planned for students through a cooperative arrangement between the school and employer as a component of work-based learning.

Definitions:

Work-Based Experiences/Apprenticeships are paid work experiences for eligible 11th and 12th grade students where experiences, hours worked, and wages earned are monitored and documented by the employer and the coordinator. (Paid work experience herein referred to as Apprenticeship)

Work-Based Experiences/Internships are unpaid work experiences for eligible 11th and 12th grade students where experiences and hours worked are monitored and documented by a supervisor/mentor and the coordinator. (Unpaid work experience herein referred to as Internship)

Standalone-with Seminar Cooperative Education Program is a program where the coordinator is not scheduled to teach any Career and Technical Education course, other than Cooperative Education Seminar, during the regular school day.

Standalone-without Seminar Cooperative Education Program is a program where the coordinator is not scheduled to teach any Career and Technical Education course during the regular school day.

Combination Cooperative Education Program-with Seminar is a program where the Coordinator teaches other Career and Technical Education courses (Agriscience, BMA, FACS, etc.) in addition to managing the Cooperative Education Program including teaching Seminar.

Combination Cooperative Education Program-without Seminar is a program where the Coordinator teaches other Career and Technical Education courses (Agriscience, BMA, FACS, etc.) in addition to managing the Cooperative Education Program without teaching Seminar.

Cooperative Education Seminar is not a required component, but can be continued as a local education agency (LEA) decision under the current regulations requiring a once per week meeting for the Cooperative Education work-based experiences/apprenticeships or internships. Students enrolled in Cooperative Education programs are not required to participate in the seminar. However, they must report weekly hours worked or hours acquired through internships. Cooperative education is supervised by a teacher who holds a Class B or higher certificate in CTE, has taken the Functions of the Coordinator or Principles of Coordination coursework, and who completes two hours of Child Labor Law training annually.

Purpose/ObjectiveThe purpose of Cooperative Education is to provide work-based experiences in approved training stations that typically cannot be obtained in the classroom.

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PrerequisitesIt is recommended, but not required, that a student obtain concentrator status, (two courses within a CTE program) prior to enrollment in cooperative education. Students who have not obtained concentrator status must have successfully completed a minimum of one CTE credit. The Career Preparedness course will count as a Career Technical course regardless of the instructor’s teacher certification. Documentation of Career Preparedness content standards achieved by the student may be used in lieu of course credit for Career Preparedness. All required reports and/or documentation (See Required Documentation, page 14) may be submitted online, in person to the coordinator during regularly scheduled job visits, or in another manner deemed appropriate by the Coordinator and LEA.

State Department of Education RequirementsThe following are essential components of on the job training (OJT) that must be in place in order for the work-based learning experiences/apprenticeships or internships to be recognized by the Alabama State Department of Education (herein referred to as the Department):

Administrative support that ensures that instructional activities promote a quality, work-based learning experience.

Qualified Work-Force Development Teacher-Coordinator (herein referred to as the Coordinator) who manages work-based learning experiences/apprenticeships or internships, in compliance with the Alabama Administrative Code, The General Business/Industry Certification Standard, and all federal and state Child Labor Laws.

Student-learners that meet student selection criteria. (See Selection of Students, page 15) Cooperative Education Seminar course offering per LEA discretion or local plan of action. Training agreements that stipulate the essential responsibilities and conditions of student

employment. Training plans that list processes, knowledge, and skills that the student is expected to learn

in the work-based experiences/apprenticeships and/or internships. Continually supervise work-based experiences/apprenticeships or internships performed in

approved training stations under the supervision of a work-place mentor and the Coordinator.

Student evaluations by the Coordinator and employer/mentor. Monthly training station communication, contact, or visits for each student.

Local Education Agency (LEA) ResponsibilitiesIt is the role of the LEA administration to ensure that instructional activities support and promote quality, work-based learning experiences/apprenticeships or internships. Positive administrative support is vital to the success of cooperative education and should be demonstrated in the following ways:

Develop written policies regarding cooperative education at least every three years in cooperation with the Coordinator to be adopted by the local board of education for use in decision-making situations and to provide guidance in achieving program goals. (See School Regulations/Policies, page 19)

Assure compliance with written state and local boards of education policies. Provide facilities and up-to-date equipment to meet Business/Industry Certification

standards. Facilitate the procurement of instructional materials. Schedule students into a regular school schedule until they are placed in work-based

experiences.

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Provide opportunities for recruitment of students through assembly programs, meetings, school visits, and other venues to create awareness of cooperative education.

Ensure the review of student transcripts to verify eligibility for participation in cooperative education. (Example: Student assessment database, Kuder)

Cooperate with the Coordinator and/or career and technical education teachers in the selection of prospective students and in making school records available. (Example: Kuder, Inow)

Provide orientation for students and parents. Visit training stations. Attend the employer-mentor orientation (recommended). (Example: administrator

occasionally accompanies the Coordinator on placement visits) Review student and teacher files for required forms: Training Agreement, Training Plan,

Application for Enrollment, Teacher Recommendations, Weekly Wage and Hour Sheet, R-1, Training Station/Agency Visit Coordinator Summary and Student Evaluations. (See Required Documentation, page 14)

Require and facilitate a monthly meeting of all personnel who supervise cooperative education to discuss programs, placements, successes, and problems.

Ensure that the student selection is equitable and addresses the needs of each student. Ensure that students accepted have met the application/selection criteria for cooperative

education and has been approved for participation by the Coordinator. Ensure that the Coordinator has a coordination period as identified in the table below:

This table is an example for a Standalone Coordinator.

Cooperative Education Coordinator

Four-Period Day (Block Schedule)

One period for planningThree periods for coordination

Five-Period Day One period for planningFour periods for coordination

Six-Period Day One period for planningFive periods for coordination

Seven-Period Day One period for planningSix periods for coordination

Provide the following financial support in order to support cooperative education:o Access to Computer Lab and Facilities when needed, classroom space, furniture, and

equipment required for Business/Industry Certification.o Local Maintenance Funds based on state standards (not less than $300 per teacher,

plus not less than $3 per student based on enrollment.).o Travel funds for the Coordinator’s work-based training supervision.

Place, when possible, the Coordinator on an extended contract that provides the time to plan and carry out required activities needed to manage the experience. This also allows for the possibility of summer work-based learning experiences/apprenticeships or internships, if desired by the LEA. The Coordinator must be on an extended contract if the student is enrolled in summer school and credit is awarded for summer work-based experience.

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ROLES AND RESPONSIBILITIES

Cooperative education requires time, commitment, and collaboration of the following partners

Students may, at the LEA discretion, meet with the Coordinator one class period per week (Cooperative Education Seminar) to maintain all required documentation and coursework and to accommodate student and/or employer needs based on individual circumstances. The LEA may use the online Kuder Portfolio for updating records and/or regularly scheduled visits by the Coordinator to meet with students. The Student must adhere to all policies of the program and training station/agency. Students must maintain transportation to continue with work-based experience.

Parents/Guardians should provide ongoing support to the student. They should support the goals and policies of cooperative education and assume responsibility for the conduct of the student. Parents/guardians must sign all required forms. Parents/guardians must arrange transportation for the student to and from the training station.

Business and community partners agree to serve as training stations/agencies providing placements for students to complete work-based learning experiences. Training mentors are responsible for evaluating student performance, ensuring that students are scheduled to meet the minimum work hours required as participants in an apprenticeship or internship, as defined in the Training Agreement, and for providing rigorous and progressive employment experiences.

Coordinators will provide ongoing supervision to the student and will manage all requirements of cooperative education. This includes, but is not limited to, collaboration with partners, selection of students, selection of training stations, placement of students, coordination of cooperative education components, documentation and submission of required reports.

Coordination of Cooperative Education ComponentsCoordination is the process of aligning administrative, organizational, and instructional activities to accomplish the objectives of Cooperative Education that requires time released from school as detailed in this manual. The Coordinator must be constantly aware of the student’s performance on the job and instructional activities for optimum results. The Coordinator ensures that normal progression takes place and that a complete series of manipulative skills is acquired. These skills are supplemented by technical and general information that will make the student a competent and well-rounded employee.

During the coordination period(s), the Coordinator performs the necessary out-of-school activities including visiting training stations, observing students at work, and consulting business individuals responsible for training the student.

Coordination functions ensure that certain essential objectives are attained: Prevent any possible exploitation of students. Determine progress of students’ performance on the job and in instructional activities. Help resolve problems that occur on the job. Increase the Coordinator’s understanding of the employer’s viewpoint. Check on student’s work performance, progress, habits, and attitudes. Evaluate the employer’s and the employee’s satisfaction with the job placement.

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Promote enforcement of the school’s policies and procedures by the employer. Collaborate with the employer to determine the student’s job performance. Make school instruction relevant to the student.

Coordinator ResponsibilitiesThe Coordinator will:

Create a Training Plan for each cooperative education participant. Complete training agreement with required signatures. It is through this training agreement

that the essential functions are outlined and agreed to by the training mentor, student, coordinator, parent, and school administrator (see Training Agreement, page 13).

Explain to the employer prior to the first written evaluation, the Work-Based Experiences/Apprenticeships or Internships Evaluation Report that rates the student on personal qualities and job tasks as defined in the Training Plan. (See Work-Based Learning Training Plan, page 23)

Secure an evaluation at least once per grading period, at the end of the semester/term, and at other times deemed appropriate.

Encourage students to become active in a CTSO related to their career objectives, career pathways, and career clusters.

Prepare students for Work-Based Experiences/Apprenticeships or Internships, expectations. Inform all students within the system of the cooperative education opportunity. Conduct an annual follow-up with employers. Conduct an annual self-evaluation to facilitate continuous improvement. Have communication, contact, or visit the training station of each student a minimum of

once per month. (More frequent communication, contacts, or visits may be required to monitor students experiencing difficulties.)

The student must have a minimum of 140 hours of apprenticeship experience or 140 hours of internship experience. The student will be awarded one credit for successful completion of the career experience. (Example: Minimum of 140 hours per period per semester on a BLOCK schedule or a minimum of 140 hours per year per period on a 7 period day) A majority of these hours should be worked Monday through Friday. (Cooperative education students may earn one credit for the completion of a work-based experience/apprenticeship or internship in the summer if they are enrolled in a formal summer school program, provided the Coordinator is on a 12-month contract).

Complete and submit reports as required by the Department and LEA, (including the R-1 report that is due November 1 and March 1).

The Coordinator needs adequate time prior to the opening of school to make business/community contacts in order to facilitate the implementation of work-based learning experiences. Making contacts in the community is critical to the success of the work-based learning experience.The Coordinator will:

Visit the business and industry leaders in the community to explain the opportunities available, as well as benefits of the work-based learning experiences to the employer.

Develop a work-based learning brochure/handbook to distribute to business, industry, the school community, and other stakeholders.

Develop a communication plan to keep the community informed regularly of work-based learning experiences. Suggested forms of media include, but are not limited to, presentations, articles, television programs, billboards, radio spots, etc.

Facilitate placement of students in employment. Participate in Program Advisory Committee meetings for all school CTE programs.

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Required DocumentationEach step in the cooperative education process has documentation that must be completed. This documentation must be kept on file a minimum of three years or as directed by LEA policy.Required documents must be on file (paper or electronic) in the Coordinator’s office and must include the following:

Individual Student Record: Application for Enrollment Resume Interview Evaluation form Training Plan Training Agreement Work-based Learning Evaluation Reports (one per grading period) Training Station/Agency Visit Coordinator Summary Wage and Hour Reports, apprenticeships and/or internships School Regulations and Policies (signed) Teacher Recommendation forms (3) including a recommendation from (3) different subject

areas. Interest/Aptitude Inventory, (example Kuder) results required. Safety training documentation. Emergency Contact Form Other forms as required by the LEA or training station.

All coordination communication, contacts, or visits must be documented. A written summary is required for each visit. Each coordination visit must include documentation of a contact with a supervisor to ensure implementation of the Training Plan and Training Agreement.When making the monthly coordination communication, contact, or visit, the Coordinator’s records may include:

Duties and tasks relative to the Training Plan. Student’s performance on assigned responsibilities and work habits including dress,

grooming, general appearance, attendance, safety, etc. Quality and quantity of work expected and performed. Student’s attitude toward the job, employer, co-workers, etc. Student’s reaction to rewards, criticism, and disciplinary action. Safety conditions of the training station. Validation of the student’s work hours for work-based experiences/apprenticeships or

internships, including punctuality and regularity of attendance. Student’s rotation through different job experiences ensuring that they are diverse, rigorous,

and progressive. Student’s preparation for position/job change or advancement. Additional opportunities for involvement in work-based learning experiences.

Extended Contract ResponsibilitiesIt is recommended that the Coordinator should be on an extended contract that provides the time to plan and carry out required activities needed to manage the experience. Listed below are a number of activities that must be completed in preparation for the next school year if the student and community needs are to be met:

Establish relationships with Industry Partners for the LEA.14

Schedule meetings with parents. Coordinate summer work-based learning experience. Locate and secure prospective training stations. Provide summer coordination for students continuing in apprenticeships or internships

throughout the summer break. Plan the instructional program. Assess and counsel students. Participate in professional development through job shadowing to meet the technical

awareness hours required by BIC.

Supervision of the extended-contract period is the responsibility of the LEA. The minimum standards for an extended contract for the Coordinator beyond the regular school term require the submission for LEA approval of a written Program of Work for the extended time period. The LEA shall have on file documentation of appropriate CTE activities with measurable goals, objectives and timelines for each teacher with an extended contract. The Coordinator must file a weekly itinerary in advance with the local CTE administrator or principal to account for time both on and off campus. (This does not exclude the LEA from requiring weekly itineraries for 9 and 10 month Coordinators during the school year.)

SELECTION OF STUDENTSThe student is the most important component in work-based learning. In all cases, the Coordinator must ensure that the student has a clearly defined career objective. Students must have the ability, aptitude, and attitude for successful employment.

In situations where students have an IEP, it is required that the Coordinator participates in the development of the Individual Education Plan (IEP) prior to placement in work-based experiences/apprenticeships or internships. It is also strongly recommended that a CTE teacher representing the cluster related to the student’s occupational objective also be included in the IEP development process.

Determination of Student EligibilityThe Coordinator will ensure that all requirements for cooperative education are met. The Coordinator ensures that the student:

Is at least 16 years of age. Is classified as an 11th or 12th grader. Is on track for graduation. Has a clearly defined career objective. Possesses the knowledge, skills, behavioral qualities, and abilities required for successful

employment. Is physically and mentally capable of performing the essential functions of the desired

work-based experience. (Essential functions are responsibilities that must be performed by the position as identified by business and industry professionals. This list should be discussed with all students and/or at all IEP meetings).

Has successfully completed the required prerequisite course, Career Preparedness, or documentation of course content objectives achieved.

Has an acceptable attendance, grade, and discipline record as validated by the Coordinator.

Has completed an Application for Enrollment.

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Has provided the names of a minimum of three educators that know, and are not related to, the student and will complete recommendation forms including the teacher of the career cluster course, if applicable.

The steps for selection are:1. Recruitment by Coordinator

A planned recruitment campaign is appropriate and necessary. Support is needed from teachers, counselors, administrators, parents, and students. Activities should be planned well in advance to articulate with overall school calendars and to have adequate time to visit feeder schools. Publicity should include purposes, career opportunities, and enrollment procedures. Designate a specific time frame for recruitment activities. The following are suggested recruitment activities:

o Classroom Visits o Posters/Flyers/Brochureso Awareness Presentationso CTSO Presentationso Assembly Programso Advisory Committee Presentations and participation for all CT Program areaso Distribution of Enrollment Information and Applications o Personal and Parental Contacto Other

2. Application by studentso To be considered for acceptance in cooperative education, the student must submit a

completed application. The application provides information relative to the student’s interests, abilities, and adaptability in relation to the chosen career objective. (See Application for Enrollment, pages 30-31)

o A minimum of three completed recommendation forms must be submitted to the Coordinator. These forms must be submitted by the current/former course teachers. Other teachers, counselors, or administrators may submit additional forms. (See Teacher Recommendation Form, page 28)

3. EvaluationThe Coordinator will accept or reject an application based on:

o Documentation and record review, such as attendance, academic and discipline.o Student interview.o Specified career objective. (Example: Listed in Kuder along with the Four Year

Plan)o Interest in learning the skills for a chosen career.o Incomplete forms

PLACEMENT OF STUDENTSThe Coordinator will ensure that all placements enhance the student’s career objective and adhere to Federal and Alabama Child Labor Laws.

Students may be employed at businesses or industries where immediate family members will be acting as their supervisor. A student may not be employed in any hazardous occupation, as defined by Federal and Alabama Child Labor Laws.

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The Coordinator could send the training mentor more than one applicant or trainee, if appropriate. If an employer wants to train a specific student, they must agree to abide by the work-based learning policies. The student’s career objective should align with the training placement and the Coordinator must approve it.

Selection of Training Stations Appropriate training stations meet the following criteria:

Comply with Office for Civil Rights regulations. Provide worker compensation insurance when applicable. Provide on the job experiences. Understand the goals and objectives of work-based learning. Collaborate with the Coordinator to identify the student’s additional training and teaching

needs. Provide rigorous and progressive occupational training and educational opportunities. Participate in the development of the student’s training plan. (See Work-Based Learning

Training Plan, page 14) Allocate time to work with the Coordinator to monitor the implementation of the training

plan and evaluate the progress of the student in meeting the goals and objectives of the work-based experiences.

Provide the required hours for work-based experiences/apprenticeships or internships for course credit.

Provide compensation information. Ensure a safe work environment and complies with local, state, and federal labor regulations

related to minors. Exemplify high ethical standards. Meet geographic requirements as defined by the LEA. Assign Interns a mentor who is willing and able to:

o Assist the student in establishing goals relative to career development, provide training to develop skills for the immediate task and future opportunities, reinforce the value and relevance of academic skills, advise the student in terms of job performance, growth opportunities, and networking.

o Coach the student on specific job skills. Reinforce the health and safety requirements in the workplace.

STUDENT INFORMATION AND REPORTINGStudent Grading The Coordinator must set high standards for students and expect high-quality work. A complete record of all grades earned must be maintained. Grades for work-based experiences/apprenticeship or internship are determined by the Coordinator through utilization of written evaluations of the students' job performance and consultation with the employment supervisor. Written employment evaluations are given at least once per grading period, and at other times deemed appropriate. It is the responsibility of the Coordinator to secure ratings from the employer on the student’s personal qualities, job performance and incorporate this information into the final grades for each student. Evaluations must be reflective of progress on skills, knowledge, and processes identified in the Training Plan. Reports are to be included in the student’s portfolio or as outlined in the Cooperative Education Seminar course in the Alabama Course of Study: Career and Technical Education.

Student Attendance

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If it is necessary for a student to be absent from the job, the students must contact the employer and the Coordinator prior to the absence to provide notification and/or secure permission.

Weekly Wage and Hour ReportCompliance with all Federal and Alabama Child Labor and minimum wage laws is required. Students may not work in a training station that would pay a lower training wage for hours worked. Each student must keep a record of hours worked each day and wages earned in an apprenticeship or internship. These records are checked weekly by the Coordinator and verified with the training station. (See Weekly Wage and Hour Report, pages 34-36)

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(SAMPLE DOCUMENT)Work-Based Learning

SCHOOL REGULATIONS/POLICIES

1. Student acknowledges that the primary purpose of Work-Based Learning is educational and, therefore, agrees to abide by the Work-Based Learning (WBL) program policies and decisions of the Cooperative Education Teacher-Coordinator, including those regarding specific job placements.

2. Student acknowledges that the school, through the Cooperative Education Teacher-Coordinator, is acting as an intermediary between the training mentor and student and that the Cooperative Education Teacher-Coordinator has a legitimate right to know and a significant role in determining the outcome of any placement issues including, termination, scheduling, assignments, and all other aspects of student placement.

3. Work-Based Learning students who fail to perform satisfactorily in all subject areas during any grading period and who fail to improve during the next grading period should be asked to resign from his/her placement.

4. A student suspended from school should not be allowed to attend their WBL placement during the suspension. On the second offense he/she may be dropped from the Work-Based Learning program with a loss of all credit.

5. A student must comply with the LEA attendance policy to participate in the program. 6. A student losing his/her WBL placement due to any action deemed unacceptable by the

school and Cooperative Education Teacher-Coordinator will be dropped from the program with possible loss of all credit.

7. A student whose WBL placement is terminated for any reason is to report to the Cooperative Education Teacher-Coordinator. Failure to do so may results in the student being dropped from the WBL program.

8. A student not attending regular school classes, and/or the Cooperative Education Seminar class (per LEA decision) cannot work at the WBL placement on the day(s) he/she is absent.

9. In case of absence, the student is required to call the Cooperative Education Teacher-Coordinator and his/her training mentor before class or working period.

10. Personal business handled at the WBL placement is prohibited.11. Friends or family are not to visit the student at the WBL placement.12. A student is to be on time at school as well as the WBL placement.13. Parents should understand the student’s responsibility to the training WBL placement and

not interfere with the performance of his/her duties.14. Business rules for dress and personal hygiene will be observed.15. Since training is the primary objective, a student is expected to remain with the WBL

placement to which he/she is assigned. Students may resign or change placements only with the express written permission of the Cooperative Education Teacher-Coordinator and following business practices for resignation. Students who fail to follow these procedures are subject to being dropped from Work-Based Learning.

16. The student organization is an integral part of a student’s Career and Technical Education program. Therefore, all students are expected to participate in and actively support the Career and Technical Education student organization that relates to their career objective.

17. When Work-Based Learning students honor their training mentors with a banquet, reception, etc., all students are expected to attend with their training mentors as their guests.

18. Students are placed to train and are under the supervisions of the Cooperative Education Teacher-Coordinator and training mentor where they are placed.

19. Students must abide by all school rules and regulations for other students and consider themselves under the jurisdiction of the school while at the WBL placement.

19

20. Transportation to and from the WBL placement is to be arranged by the student/parent/guardian. Transportation problems do not justify absence from the WBL placement.

21. Students will leave the campus immediately following the last scheduled class. If for any reason a student needs to remain on campus, permission must be obtained from the Cooperative Education Teacher-Coordinator, School Administrator, or CTE Instructor.

22. Other local additions

*I have read the foregoing rules for Work-Based Learning students and agree to follow them.

Student Signature _______________________________________ Date _________________

Parent/Guardian Signature_________________________________ Date _________________

20

(SAMPLE)TRAINING AGREEMENT

FORWORK-BASED LEARNING

Student’s Name __________________________________ Birth Date ____________ Age Student’s Address Telephone ____________________ Cell Phone _________________ E-mail Current Career Objective/Pathway _______________________ Job Title School Name ________________________________________ System Work-Based Learning Site __________________________________ Telephone WBL Site Address WBL Supervisor ____________________________ Mentor Date Training Period Begins ______________________________ Ends

This training agreement briefly outlines the responsibilities of the student, parents, employer, and the Cooperative Education Teacher-Coordinator. The second part of this document is entitled “Training Plan” and consists of tasks and competencies for the specific student’s career objective/pathway.

Parent/Guardian1. Approves and agrees that the student may participate in Work-Based Learning.2. Encourages the student to effectively carry out the work experience requirements in all

components of the program.3. Assumes responsibility for the conduct of the student.4. Arranges transportation for the student to and from the Work-Based Learning site.5. Holds school and Cooperative Education Teacher-Coordinator harmless for risks associated with

transportation and indirectly monitored activities (e.g., work-based experience).

Student1. Complies with the rules and regulations of the Work-Based Learning site.2. Observes the same regulations that apply to other employees.3. Adheres to all policies and regulations as set forth by school administration and the Cooperative

Education Teacher-Coordinator.4. Works an average of 15 hours each week.5. Will not pursue additional part-time employment while enrolled in Work-Based Learning.6. Will not displace adult workers who can perform such work as assigned in the work-based

experience.7. Attends an annual employer appreciation if required by the Cooperative Education Teacher-

Coordinator.

21

Cooperative Education Teacher-Coordinator1. Assists in securing an appropriate work-based experience based on the student’s career

objective/pathway.2. Works with the supervisor/mentor in developing a training plan for the student.3. Communication/Contacts/Visits the Work-Based Learning site at least once per month to contact

the employer and student; verify that student’s duties correlate with job description; observe working conditions; help develop progressive skill-building activities; observe and evaluate student progress; and/or resolve questions, issues, concerns, etc.

4. Counsels the student about his/her job progress, behavior, attitude, academics, etc.5. Terminates employment/participation when it serves the best interest of the student as

determined in collaboration with the employer.6. Determines the student’s final grade with input from the OJT mentor/supervisor for the

Work-Based Learning experience.7. Reinforces work-based learning experiences with related classroom instruction.

Employer/Training MentorRecognizes that the student is enrolled in a Work-Based Learning experience designed to prepare for a career in ________________________________.1. Provides supervision and instruction in each of the applicable tasks listed on the Training

Plan to assist the student in acquiring those competencies necessary for success in the career objective.

2. Evaluates and documents student progress.3. Employs a non-discrimination policy with regard to race, color, handicap, sex, religion,

national origin, creed, or age.4. Adheres to wage and hour, child labor, and all other federal, state, and local laws pertaining

to student employment and safety.5. Employs/interns the student for an average of 15 hours per week. (140 hours per Credit)6. Completes the Work-Based Experience Evaluation and returns it to the Cooperative

Education Teacher-Coordinator by the required date.

The (Name of Recipient/LEA) does not discriminate on the basis of race, color, national origin, sex, disability, or age in its programs and activities and provides equal access to the Boy Scouts and other designated youth groups. The following person(s) has been designated to handle inquiries regarding the non-discrimination policies:

Name and Title (i.e. 504 Coordinator or Title IX Coordinator)Address Telephone NumberE-mail Address


_______________________ (Parent/Guardian)

_______________________ (Employer/Training Mentor)

______________________ (Student)

_______________________(Co-Op Teacher/Coordinator)

_______________________ (School Administrator)

______________________ (Date)

22

(SAMPLE)Work-Based Learning Training Plan

Student’s Name: _____________________________________ Date: _____________________________________

Career Objective/Pathway: ________________________ Job Title: _____________________________________

Employer’s Name: ________________________________ Supervisor/Mentor: _____________________________

Directions: List each task (processes, knowledge, and skills) that will be performed by the student under the supervision/guidance of a work-place mentor. The student should rotate through different job experiences, ensuring that they are diverse, rigorous, and progressive. Throughout the training period, check the appropriate number in the rating column below to indicate the degree of competency for each task. The descriptions associated with each of the numbers focus on the level of student performance for each of the tasks listed below. This document will be used for discussion during monthly communication/contacts/visits and to prepare the work-based experience evaluation.

Employer’s Rating Scale4 - Skilled--can work independently with no supervision.3 - Moderately Skilled--can perform job completely with limited supervision.2 - Limited Skill--requires instruction and close supervision.1 - No Exposure--no experience or knowledge in this area.

TasksTask Progress Rating

Learning StatusOn-Going

Date Objective Reached

1

2

3

4

23

(SAMPLE)WORK-BASED LEARNING

EXTENDED CONTRACT DUTIES AND RESPONSIBILITIESFOR COOPERATIVE EDUCATION TEACHER-COORDINATOR

1. Conduct and/or update the Business/Community Survey to ascertain number and type of employment opportunities available and/or anticipated Work-Based Learning (WBL) placements.

2. Process individual application forms for each student planning to enroll in the Work-Based Learning programs. Develop tentative training agreements and training plans. Process appropriate documents. (Business/Industry Certification)

3. Contact new students’ parents/guardians; explain the WBL program and discuss responsibilities of school, student, parent, and training placement. Establish purpose of training agreement and training plan. (Business/Industry Certification)

4. Plan employability skills training, leadership development, and skill enhancement as an integral part of instruction. (Business/Industry Certification)

5. Place students in WBL sites for paid work experience to develop their career objective. (Business/Industry Certification)

6. Conduct monthly communication/contacts/visits to the work site to determine student progress and changes needed in Work-Based Learning programs. (Business/Industry Certification)

7. Visit new and expanding industries and businesses to identify new skills, equipment, and materials that may be incorporated into the curriculum. Solicit materials from related industries and other agencies to be used in classroom and laboratory activities.

8. Adapt classroom instruction (if applicable) to conform to the course of study and changes in business and industry. (Business/Industry Certification)

9. Conduct safety checks of all equipment, hazardous materials, and facilities as appropriate. (Business/Industry Certification). (if applicable)

10. Facilitate the repair of equipment and classroom maintenance to ensure students’ safety and maximum use of the equipment. (Business/Industry Certification). (if applicable)

11. Prepare Career and Technical Education Implementation Plan for students with disabilities who have previously been identified for the program. (Business/Industry Certification,)

12. Assess and inventory equipment, facilities, materials, and supplies and initiate orders as necessary before beginning of school year (if applicable).

13. Work with counselor for the purpose of interpreting test results of pre-registered students to determine learning needs of students and appropriate placement of students. (Business Industry Certification)

14. Participate in appropriate in-service programs, technical conferences, and workshops/seminars to improve teaching techniques and enhance professional development. (Business/Industry Certification)

15. Ensure that the classroom is clean and orderly. Arrange for safe storage of hazardous materials and equipment (if applicable). (Business/Industry Certification)

16. Prepare appropriate public relations materials when meeting with business, industry, and community organizations.

17. Update all files, enrollment forms, student records, etc. (Business/Industry Certification)18. Develop and update community resource lists of business and industry personnel who can provide assistance

with Work-Based Learning programs.

Quality Factors (QF) are taken from Career and Technical Education General Program Business/Industry Certification Checklist.

24

R-1 Cooperative EducationWork-Based Learning Report

Alabama State Department of EducationCareer and Technical Education/Workforce Development

P. O. Box 302101Montgomery, Alabama 36130-2101

Due: November 1 and March 1

Coordinator’s Name: Approved:(Local Career and Technical Education Administrator)

Email Address:

School: Signed:(Cooperative Education Teacher-Coordinator)

School System:

Submission date: Date:

Standalone Program: (Full-time)

Combination Program: (Part-time) Email one copy to [email protected]

All Students participating in Work-Based Experiences must be on track for graduation.

Student Name

Age Sex

Gra

deIE

PA

ppre

ntic

eshi

p

Inte

rnsh

ip Title of Career and Technical Education

Eligibility Course

Student’s Career Objective(Program Cluster Area)

Student’s Specific Job Title Name of Training Station

1. John Doe (Example) 17 M 11 N Y N Career Preparedness Architecture and Construction Welder Widget Fabricators, Inc.2. 3. 4. 5. 6. 7. 8. 9.

10. 11. 12. 13. 14. 15. 16. 17. 18. 19. 20. 21.

25

Revised: 11/24/2014

22. 23. 24. 25.

Student Name

Age Sex

Gra

deIE

PA

ppre

ntic

eshi

p

Inte

rnsh

ip Title of Career and Technical Education

Eligibility Course

Student’s Career Objective(Program Cluster Area)

Student’s Specific Job Title Name of Training Station

26. 27. 28. 29. 30. 31. 32. 33. 34. 35. 36. 37. 38. 39. 40. 41. 42. 43. 44. 45. 46. 47. 48. 49. 50. 51. 52.

26

53. 54. 55. 56. 57. 58. 59. 60.

27

(SAMPLE)

Work-Based Learning Evaluation ReportTrainee Supervisor/Mentor Job Title Agency

Directions: Evaluate the personal qualities below for your trainee. Rate the student’s performance by using the numerical key below to mark the appropriate space. List the specific job tasks that are performed by the student each grading period. Your report will be used in determining a grade and for counseling the trainee. Careful attention should be given so as to present a true picture of your trainee’s work and progress each grading period.

Essential Skills/Job Tasks Key: Excellent (9-10) Good (6-8) Fair (3-5) Poor (1-2) Unacceptable (0)

Rating of Trainee for Year __________ - __________

Essential SkillsGrading Period

1 2 3 4 5 6Attendance: Attendance: Present and on time, begins work promptly

Appearance: Work dress, grooming, lean, and general appearance, etc.

Dependability: Able to work with little supervision, follows instructions, consistent, etc. Leadership: Initiative, eager to learn, resourceful, good judgment, able to inspire others, etc.

Thoroughness: Accurate, careful, completes work, etc.

Ability To Get Along With Others: Tactful, friendly, cooperative, etc.

Transferable Job Skills: Good attitude, self-control, honesty, etc.

Work Ethics: Works overtime, performs extras, etc.

Progressive Job Tasks(List specific job tasks performed from Training Plan.)

Grading Period1 2 3 4 5 6

TOTAL (Personal Qualities + Job Tasks)

Average: Total ÷Total Possible Points

Evaluator’s Signature: ____________________________________ Date: _________________________________

28

(SAMPLE)

TEACHER RECOMMENDATION FORM

_______________________________ has applied for enrollment in the _____________________ (Activity Name) Work-Based Learning program. Students in this program may receive classroom instruction in workplace practices and procedures, and are placed in training stations where they develop skills and obtain valuable experience under supervision. The cooperation of business and industry will continue only if the students they employ have the proper attitude and interest to profit from on-the-job training toward a career objective/pathway. Using your knowledge of the student, please rate the student on the characteristics indicated.

Rate qualities by checking the proper right-hand column. Poor

Below Average Average

Above Average Superior

Dependability: Able to work with little supervision, prompt, sincere, consistent, truthful, follows instruction, etc.Cultural Refinement: Courteous, considerate, good manners, appreciative, etc.Leadership: Resourceful, able to inspire others, etc.

Industriousness: Persistent, good work habits, makes wise use of time, etc.Thoroughness: Accurate, completes work carefully, etc.Appearance and Grooming: Clean, neat appearance, orderly, etc.Ability to Get Along With People: Adaptable, friendly, tactfully, cooperative, respectable, etc.Social Habits: Good attitude, self-control, honesty, not inclined to argue or complain, etc. Attendance: Present and on time, begins work at once without delay, etc. Mental Alertness: Attentive, interested, observing, eager to learn, etc.Academic Performance: Completes assignments, follows instructions, meets deadlines, masters content, etc.

Other Comments: (use the back of this page for additional comments if need) ____________________________________________________________________________________________________________________________________________________________EmployabilityIf you were an employer or job supervisor, would you want this student working for you? ( ) Yes ( ) NoWould you be willing for this student to represent the school on the job? ( ) Yes ( ) No

Signature__________________________________________ Date_________________ (Evaluating Teacher)

29

(SAMPLE) Emergency Contact Form

Emergency Contact Information

Please provide the name, address, and telephone number of two persons who may be contacted in the event of an emergency:

Name and Relationship: __________________________________________________________

Home Street Address: ___________________________________________________________

______________________________________________________________________________

Home Telephone:________________________ Cell:______________________________

Business Telephone:______________________

E-mail: _______________________________________________________________________

Name and Relationship: __________________________________________________________

Home Street Address: ___________________________________________________________

______________________________________________________________________________

Home Telephone:______________________ Cell:___________________________________

Business Telephone: ____________________________________________________________

E-mail: _______________________________________________________________________

30

(SAMPLE)APPLICATION FOR ENROLLMENT

PLEASE PRINT OR KEY ALL INFORMATION REQUESTED EXCEPT SIGNATURE.

Date ___________________________________

Name Last First Middle Maiden

Present Address Number Street City State Zip

Telephone ( ) Cell Phone ( ) e-mail:

Age Date of Birth [ - - ]

Do you have a driver’s license? Yes No Do you have access to a car/other mode of transportation? Yes No

Career Objective: 1st Choice____________________ 2nd Choice____________________ 3rd Choice___________________

Parent/Guardian Name(s) Parent Cell Phone ( )

e-mail:

Parent/Guardian Address Number Street City State Zip

Indicate the type of business in which you prefer to work: (Example: bank, dental, retail store, legal, manufacturing,

insurance, automotive, medical, etc.)

First Choice____________________________ Second Choice __________________________

Do you intend to further your formal education after high school? Technical training 2 yr. 4yr military work full-time

Are you under a doctor’s care? Yes No Do you have any health problems that would interfere with your regular

attendance on a job? Yes No If yes, please explain ___________________________________________________

Current or Previous Work Experience(List most recent position first.)

Employer Type of Work Employment Dates

Current Class Schedule

Class Teacher Grade Point Avg.

1st Period

2nd Period

3rd Period

4th Period

31

5th Period

6th Period

7th Period

List as references the names of three teachers who can attest to the quality of your work.

1. _________________________________ (Career and Technical Education Teacher if applicable )

2. _________________________________

3. _________________________________

To the Student:

Work-Based Learning provides an opportunity to be considered for apprenticeship/internship in business and industries in our area. You further understand that NO apprenticeship or internship is guaranteed. You must apply, interview and compete for the placement based on your skill, your abilities and your aptitude. When you enroll in Work-Based Learning, you indicate that you are sincerely interested in putting forth your best efforts to receive work-based experience. If you accept this responsibility, please sign in the space provided.

Student Signature ________________________________________________ Date _______________________________

To the Parent/Guardian:

Do you consent to your child entering Work-Based Learning, arranging transportation, and agree to cooperate with the school and the training agency in making the training and education of the greatest possible benefit to your child? If so, please indicate your support and approval with your signature.

Parent/Guardian Signature: ________________________________________ Date _______________________________

To Be Completed by the Cooperative Education Teacher-Coordinator.

On Track for Graduation: ____yes _____No Successful completion of Career Preparedness: ____Yes ____No Current Attendance Record: No. Absences ________ No. Tardies ____________ Current Disciplinary Record: Total Reports ________ Cumulative GPA: ________

List Career and Technical Occupational Courses or Career Objective that determine student’s potential placement:

1. ____________________________________ 3. __________________________________

2. ____________________________________ 4. __________________________________

Verified By __________________________________________________ Counselor/School Administrator/Cooperative Education Teacher-Coordinator

Status of Application: Pending Approved Not Approved

32



Name and Title (i.e. 504 Coordinator orTitle IX Coordinator)Address Telephone NumberE-mail Address


QUESTIONS FOR STUDENT INTERVIEW(For Student Selection)

1. What do you believe is the purpose of Work-Based Learning?

2. Why do you want to enroll in Work-Based Learning?

3. Have you ever been employed before? If so, describe your job.

4. What are your plans following high school? Have you considered additional training?

5. In what ways will Work-Based Learning help you?

6. Is there any reason why you could not work fifteen (15) to twenty (20) hours weekly next year? What are your plans to participate in activities during your final year at high school?

7. Are you currently a member of a student organization? Why? Why not?

8. What subjects do you find most enjoyable?

9. What special training would you expect to receive from your Apprenticeship/Internship ?

10. Where did you first hear about Work-Based Learning?

11. What do you want to do to earn a living?

12. How do you learn outside of the classroom?

13. What courses do you plan to take next year?

14. What are your arrangements for transportation?

33

15. Would you change your appearance to become employed or be retained in employment? (cut hair, no nail color, short nails, no miniskirts, remove piercings , cover tattoo etc.)

16. Do you have a preference of where you would like to work?

17. Other


INTERVIEW EVALUATION FORM

Student Interviewed: __________________________ Career Objective:__________________

Above Average Average Poor

Appearance

Personality

Desire to be enrolled in the program

Concept of program’s purpose

Summary of student’s interests, abilities, and adaptability relative to career objective: ____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Student’s plans following high school: ____________________________________________________________________________________________________________________________________________________________________________________

34

Work experience: ______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Reaction when asked if he/she would change personal appearance in order to become employable or keep employment: __________________________________________________________________________________________________________________________________________________________________________________Discussion of student organization (CTSO): __________________________________________________________________________________________________________________________________________________________________________________Current Employment if any: _________________________________________________________________________________________Comments: ___________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

35


WEEKLY WAGE AND HOUR REPORT

Student____________________ Job Title____________________Training Station_____________________Supervisor_____________________

Month_______________ Year______ Supervisor’s Initials Month_____________ Year_______ Supervisor’s Initials

Number of Hours Worked Total Hours

Worked

Rate of Pay

Total Gross Wages


Worked

Rate of Pay

Total Gross WagesWeek Sun Mon Tues Wed Thur

s Fri Sat Week Sun Mon Tues Wed Thurs Fri Sat

1 1

2 2

3 3

4 4

5 5

Total Total



Worked

Rate of Pay

Total Gross Wages


Worked

Rate of Pay



1 1

2 2

3 3

4 4

5 5

Total Total

36

Student____________________



Worked

Rate of Pay

Total Gross Wages


Worked

Rate of Pay



1 1

2 2

3 3

4 4

5 5

Total Total



Worked

Rate of Pay

Total Gross Wages


Worked

Rate of Pay



1 1

2 2

3 3

4 4

5 5

Total Total

37

Student ____________________



Worked

Rate of Pay

Total Gross Wages


Worked

Rate of Pay



1 1

2 2

3 3

4 4

5 5

Total Total

CUMULATIVE RECORD

July Aug Sept Oct Nov Dec Jan Feb March April May June

Hrs. Fwd

Hrs. This Month

Hrs. Y-T-D

Wages Forward

Wages This MonthWages Y-T-D

38

(SAMPLE)ORIENTATION TO BUSINESS

STUDENT’S NAME___________________________________ DATE _________________________________

TRAINING STATION/AGENCY________________________ SUPERVISOR

Instructions: Please provide the following information to your student employees. Check each item as it is completed. Return the completed form to the Cooperative Education Teacher-Coordinator.

Company Orientation

_____ 1. Give student copies of printed materials (handbook, brochures, etc.)._____ 2. Explain the company’s history._____ 3. Describe the company’s service/product line(s)._____ 4. Discuss company policies and procedures regarding:

( ) Hours of operation/work ( ) Overtime policies ( ) Pay time period ( ) Vacation policy ( ) Holiday policy ( ) Appropriate dress and grooming ( ) Safety rules/Regulations ( ) Emergency procedures ( ) Absentee procedures ( ) Parking ( ) Arrival procedures ( ) Departure procedures

_____ 5. Describe employee benefits such as: ( ) Discounts ( ) Educational assistance

_____ 6. Describe the relationship of the department to the company (if applicable). _____ 7. Discuss specific company/departmental rules including:

( ) Breaks ( ) Work schedules ( ) Days off

( ) Presence of food at work station_____ 8. Introduce co-workers._____ 9. Explain job responsibilities of co-workers._____10. Identify training sponsor/mentor.

Job Orientation

_____11. Show student her/his workstation._____12. Describe student’s responsibilities._____13. Explain the importance of the student’s responsibilities to the organization._____14. Explain Safety Procedures and Emergency Situations.

___________________________________________________ (Employer/Mentor) (Date)

___________________________________________________ (Student) (Date)

39

(SAMPLE)GENERAL SAFETY EXAM

Quiz_safetyvideoquiz.pdf (View online)

1. T or F Personal protective equipment (PPE) is only made for the head, face and eyes.

2. T or F A hard hat should provide a one-inch space between your head and the outer shell.

3. T or F Hair clips, earrings, eyeglasses, and even you own hair can reduce the effectiveness of earmuffs.

4. T or F Earplugs fit over the entire ear.

5. T or F Respirators are only necessary if you are working an oxygen-deficient work environment.

6. T or F Gloves should not be worn when working with or around machinery with moving parts.

7. T or F Pulling a heavy load is easier on you back than pushing it.

8. T or F You can help prevent slips, trips, and falls with good housekeeping practices.

9. T or F Wet entrances and exits can increase the risk of slips and falls.

10. T or F Trip hazards, such as uneven surfaces, curled or loose carpeting, or extension cords across a traffic area, should be reported at you next employee evaluation meeting.

11. T or F Labels will always list what type of PPE to wear while handling that particular material.

12. T or F If you remove a label, you should replace it with an accurate label immediately.

13. T or F Although the format of MSDS may vary, they all contain the same basic information.

14. T or F You should avoid getting blood or other potentially infectious body fluids from an injured co-worker directly on you skin, eyes, nose, or mouth.

15. T or F Blood and body fluids can carry viruses like HIV and the hepatitis B virus.

16. T or F Applying a lock or tag to an energy source is only one step in the standard six-step lockout/tagout procedure.

17. T or F You can remove someone else’s tag and restore power to a machine if you check to make sure that nobody is currently working on it.

18. T or F Always stay and fight a fire with extinguisher until the fire department arrives.

19. T or F Keeping fuel or flammable materials away from ignition sources can help prevent fires.

20. T or F When you practice basic safety procedures, you are helping to make your work environment a safe place fro everyone.

40

(SAMPLE)TRAINING STATION/AGENCY CONTACT

COORDINATOR SUMMARY

Student’s Name ____________________________ Job Title Training Station/Agency _______________________________ Supervisor Contact Person (today’s visit) Date:

Purpose of Visit: Student Observation Student Evaluation Counseling Problem Resolution Other

This form must be completed each month for training station/agency visits. Record observations, actions to be taken, and recommendations. Identify specific strengths and needed improvements.

General Observations:

Student Activity During the Observation:

Student Conference/Comments:

Training Mentor Conference/Comments:

Cooperative Education Teacher-Coordinator’s Overall Comments On This Visitation:

During the visit, the Cooperative Education Teacher-Coordinator confers with the employer or trainer to discuss one or all of the following items:

1. Duties and tasks relative to the agreed training plan.2. Student’s performance on assigned responsibilities and work habits.3. Quality and quantity of work expected and performed.4. Student’s attitude toward the job, employer, co-workers, etc. rewards,

criticism, and disciplinary action.5. Safety conditions.

6. Validation of the student’s work hours including punctuality and regularity of attendance.

7. Student’s rotation through different job experiences, insuring that they are diverse, rigorous, and progressive.

8. Student’s preparation for position/job change or advancement.

9. Additional opportunities for involvement in the Cooperative Education program.

10. Additional opportunities for partnering with Career and Technical Education, i.e. competition judge, resource speakers.

Signature:________________________________________________ (Cooperative Education Teacher-Coordinator)

41

(SAMPLE)COOPERATIVE EDUCATION TEACHER-COORDINATOR’S

EXTENDED CONTRACT PROGRAM OF WORK(Local Use Only)

Month/Day Objective Implementation Measurable Evaluation

42


EXTENDED CONTRACT ITINERARY FORCOOPERATIVE EDUCATION TEACHER-COORDINATOR

Name

School

Itinerary for week of (Month) (Date) (Year)

Day Places/Persons Work To Be DoneMonday AM

PM

Tuesday AM

PM

Wednesday AM

PM

Thursday AM

PM

Friday AM

PM

Note: Make three copies - One for principal/CT Administrator, one for local supervisor (if applicable), and one for personal files. For local use only.

43

(SAMPLE)COOPERATIVE EDUCATION TEACHER-COORDINATOR’S

BUSINESS/COMMUNITY VISITATION LOG

Month ___________________

Date * Name of Business Person Contacted/Position Response

*Check if first time contacted.

___________________________________________________________ Cooperative Education Teacher-Coordinator’s Signature

44

(SAMPLE)

COOPERATIVE EDUCATION TEACHER-COORDINATOR’S MONTHLY TRAVEL LOG

Name ____________________________ Month ______________________ Year _____________

DATE

FROM

TO

PURPOSE OF TRAVEL

CONTACT PERSON

MILEAGE

Submit this form monthly to the designated LEA official.

45

ALABAMA STATE DEPARTMENT OF EDUCATIONAPPROVED NATIONAL ACADEMY INTERNSHIPS

DefinitionAn Academy Internship is a work-based learning experience that is included as a part of an ALSDE-approved Career and Technical Education Academy.

Purpose/Objective: ExplorationThe major purpose of Academy Internships is for the student to learn content standards, explore careers, and gain knowledge about specific occupations not normally experienced in the classroom.

PrerequisitesStudents must be enrolled in an ALSDE-approved academy that requires an integrated internship.

Related InstructionStudents must be enrolled in an approved academy related to the internship placement. Students will meet with the Coordinator and/or the related instruction teacher prior to beginning an Academy Internship to outline expectations and responsibilities.

Student Selection/Qualifications:The student must:

Be at least sixteen years of age. Be physically and mentally capable of performing the tasks of the career objective. Be classified as an eleventh or twelfth grader. Be in good academic standing and have an acceptable discipline record as determined by the related

instruction teacher or Coordinator.

Roles and ResponsibilitiesAcademy Internships require time, commitment, and collaboration of the following partners:

Students are responsible for maintaining all required documentation and adhering to all policies of the internship site.

Parents/Guardians provide ongoing support to the student. The Academy Teacher approves internship sites. If applicable they are responsible for working with the

Coordinator to provide supervision of the internship. The Coordinator provides assistance in locating Academy Internship sites and if applicable, ongoing

supervision of the student. Business and community partners provide opportunities and placements for students to complete

internship activities related to the academy’s objective.

Appropriate PlacementAll academy internship sites must relate to the academy’s objective. The internship site /agency must adhere to all federal and state Child Labor Laws.

Credits EarnedN/A

46

Hour RequirementsHour requirements for the internships will be determined by the Academy requirements.

Supervision/Coordination RequirementsThe Coordinator and/or the academy teacher must make an on-site visit to the internship site a minimum of once a month during the internship, and maintain all required academy documentation for each student participating.

Job Placement Restrictions or LimitationsStudents may not intern at businesses or industries where immediate family members will be the internship supervisor or in any hazardous occupation as defined by federal or state Child Labor Laws.

Required Documentation and Forms:The documentation as required by the academy.

Insurance Coverage:All students must show proof of current liability automobile insurance.

WagesCompliance with all federal and state Child Labor and minimum wage laws is required. Students may not work in a training station that would pay a lower training wage for hours worked. Each student must keep a record of hours worked each day and wages earned. These records are checked weekly by the Coordinator and verified with the training station. (Weekly Wage and Hour Report)

HEALTH SCIENCE CLINICAL INTERNSHIP

DefinitionHealth Science Clinical Internship is a structured component of the Career and Technical Education Health Science curriculum that provides a supervised experience in an approved setting. Health Science Clinical

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Internship is designed to be completed in a hospital, extended care facility, rehabilitation center, medical office, imaging laboratory, or other approved setting(s). The Health Science Clinical Internship standards are identified in the Alabama Course of Study: Career and Technical Education as part of the coursework for Health Science.

Purpose/Objective: Occupational PreparationHealth Science Clinical Internship provides an opportunity for students to gain knowledge and apply previously learned theory and skills in an actual health care setting. These experiences are uniquely designed to meet students’ career objectives through supervised experiences, which are coupled with related classroom instruction.

PrerequisitesSuccessful completion of a minimum of one credit in Health Science coursework is required prior to placement of a student in Health Science Clinical Internship.

Related InstructionStudents must be enrolled in a Health Science course. The student shall participate in Health Science Clinical Internship for a maximum of three (3) days a week. Students must participate in classroom instruction a minimum of two days per week for mastery of content standards, documentation of technical skill attainment, and discussion of internship experiences. The number of days for clinical and classroom instruction can be used as an average number of days per week.

Student Selection/QualificationsHealth Science Clinical Internship student must:

Be at least sixteen years of age. Meet the prerequisites for enrollment and have declared a Health Science career objective. Complete a Health Science Program Application for Clinical Enrollment. Be capable of performing the tasks of the clinical placement. Be classified as an eleventh or twelfth grader. Be in good academic standing and have an acceptable discipline record as determined by the Health

Science teacher.

Roles and Responsibilities

Health Science Clinical Internship requires time, commitment, collaboration of the following partners:

Students must arrive at the clinical site at the appropriate time and in the appropriate dress. Students must comply with the rules and regulations of the school district, school, and clinical site.

Parents/Guardians should provide ongoing support to the student and assume the responsibility for the conduct of the students. Parent/guardian is responsible for transportation arrangements for the student to and from the clinical site and will be responsible for any liability involved.

Health Science Teachers shall secure appropriate clinical site(s) based on the student’s career objective. The teacher shall work with the clinical site(s) to develop a training plan for the student. The teacher will monitor student progress through visits and/or communication with clinical site preceptor(s) or their designee. The teacher shall meet with the student regarding his/her progress, behavior, attitude, academics, etc. and is responsible for the student’s final grade for clinical experience. The teacher is also responsible for reinforcing clinical site experiences with related classroom instruction.

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Healthcare Clinical Preceptor(s) shall provide opportunities and placements for students to apply previously learned theory and skills in healthcare settings, as well as a safe learning environment. Clinical Preceptor(s) will evaluate student performance and report to Health Science teacher.

Appropriate PlacementHealth Science Clinical Internship provides opportunities for a student to meet their career objective and train in areas outside of their primary objective in order to gain a broader perspective. Clinical placements must also meet federal and state Child Labor Laws.

Credits Earned Credits will reflect the course requirements in which the clinical internship is incorporated.

Hour Requirements Student must successfully complete 140 hours that include both classroom and clinical instruction to earn one course credit.

Supervision/Coordination RequirementsThe Health Science teacher will monitor student progress through visits and/or communication with clinical site preceptor(s) or their designee.

Placement Restrictions or Limitations Student may not participate in a hazardous occupation as defined by Alabama and Federal Child Labor Law. Student may be rotated to a different clinical site based on a student’s career objective or area of interest at the discretion of the Health Science teacher.

Required Documentation and FormsThe following documentation or forms must be completed and placed in the student file with the Health Science teacher for each student participating in Health Science Clinical Internship. The documents and forms must be kept on file a minimum of five (5) years.

Prior to Enrollment: Career Interest/Aptitude Inventory (Assessment used to be determined by the LEA) Health Science Program Application School/LEA Clinical Regulations and Policies (To be established and approved by the LEA)

Prior to Placement of Student: CPR Certification (American Red Cross or American Heart Association) Health Science Clinical Internship Training Agreement Health Science Clinical Internship Time Sheet Health Science Clinical Internship Evaluation of Student Performance Student Confidentiality Statement Other Forms/Documents as required by the Health Science Teacher, Local Education Agency, or

Training Site

WagesHealth Science Clinical Internship is unpaid work experiences.

Insurance Coverage/ImmunizationsAll participants in Health Science Clinical Internship must provide proof of the following:

Current health insurance coverage Liability insurance coverage

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Automobile liability insurance (if student provides own transportation) Hepatitis B Vaccine Varicella Vaccine (or diagnosis of varicella or verification of history of varicella disease) Current TB Skin test Other Forms/Documents as required by the Health Science Teacher, Local Education Agency, or

Training Site

(SAMPLE)HEALTH SCIENCE

PROGRAM APPLICATION

PLEASE CHECK YOUR APPROPRIATE GRADE LEVEL FOR THE UPCOMING SCHOOL YEAR

9th grade _____10th grade _____11th grade _____12th grade _____

PLEASE CHECK ALL THE FOLLOWING THAT APPLY TO THE UPCOMING SCHOOL YEAR

I will be a 1st year Health Science student _____I will be a 2nd year Health Science student _____I will be a 3rd year Health Science student _____I will be a 4th year Health Science student _____I am applying for Health Science Clinical Internship _____

STATE YOUR CAREER OBJECTIVES

First Career Objective ________________________ Second Career Objective ________________________

STUDENT INFORMATION

Name _________________________________ Age ______ Date of Birth ____________ Date _____________

Home School ______________________________ Home Address ______________________________________

Home Telephone ____________________________________ Cell Telephone ___________________________

Mother’s Name/Legal Guardian ____________________________________ Telephone __________________

Father’s Name/Legal Guardian _____________________________________ Telephone __________________

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Are you employed? _________ If so, where? _______________________________________________________

Graduation Exam Passed _____ Yes _____ No ACT Score ___________ Current GPA __________

How many days were you absent this school year? __________ If over 5, please explain ____________________

Do you have any health problems or allergies? ________ If yes, explain _________________________________


Name and Title (i.e. 504 Coordinator or Title IX Coordinator)

Address Telephone NumberE-mail Address



ATTACH THE FOLLOWING Please write a paragraph describing what you hope to gain from the Health Science program and why you decided on your career objective.


CLINICAL INTERNSHIP TRAINING AGREEMENTTraining Agreement Between Health Science Program and Health Agency

THIS AGREEMENT, made and entered into this ____________ day of _______________, 20____, by and between ___________________________________ in __________________, party of the second part.

WITNESSETH:

WHEREAS, ______________________________________(school name), is desirous of establishing a healthcare education opportunity at ___________________________________ (Health Agency) in which students will observe and perform such duties as permitted, and

WHEREAS, the party of the second part is desirous of improving the quality of trained employees and recognizes the need for such healthcare education experience.

NOW, THEREFORE in consideration of mutual covenants hereinafter set forth, _____________________ ______________________________(school name), and party of the second part do hereby agree as follows:

1. Students shall be subject to the rules and regulations of the establishment of the party of the second part at all times and during the periods of observing and performing practical experiences on the premises, shall be under the supervision, control, and direction of the party of the second part and any student failing to conduct himself/herself accordingly is subject to dismissal from the program by either party of the first part or party of the second part.

2. The student shall have liability insurance coverage that meets approval of the party of the second part.

3. The number of hours that the student will spend on the premises of the party of the second part and the duties to be performed shall be agreed upon by both parties.

4. Students shall receive instruction in the aforementioned duties prior to assignment by either the training program or the party of the second part, or both. The students will strictly abide by the compliance policies and procedures and agrees to report any compliance issues to the appropriate parties.

5. Students shall maintain confidentiality at all times. Breach of confidentiality will result in dismissal from the program by either party of the second part or party of the first part.

6. Neither party shall discriminate on the basis of race, color, creed, sex, national origin or ancestry, disability, or age in access to, treatment in or benefits under this agreement.

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7. Transportation both to and from the premises will not be provided by either party and will be the student’s responsibility unless otherwise agreed upon.

8. The second or first party reserves the right to terminate this agreement at any time, if the rules and regulations stipulated herein are violated.

9. The second or first party will not be held liable for accidents that may occur while the student is in or on the premises of the clinical site.

10. If any of the provisions of the Agreement are in conflict with any applicable statue, rule or law, then such provision shall be deemed inoperative to the extent they conflict herewith and shall be deemed to be modified to conform to such statute and rule.






______________________________________________________________ School Administrator

______________________________________________________________ Healthcare Science Teacher

______________________________________________________________ Administrator, Party of the Second Part (Agency or Department as designated)

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(SAMPLE) HEALTH SCIENCE CLINCAL INTERNSHIP

TRAINING AGREEMENT

BY AND BETWEEN____________________ HOSPITAL AND _______________________ SCHOOL

This agreement entered into this _____ day of ___________, 20 ____, by and between the ____________ City Board of Education, for ____________________ High School, hereinafter referred to as “_______________” and the Health Care Authority of the City of ________________, hereinafter referred to as “_______________ Hospital.”

WHEREAS, ____________ Hospital operates as a hospital in _____________, Alabama with facilities available for education and training in health careers; and

WHEREAS, ____________ provides training in health careers; and

WHEREAS, both parties benefit from an agreement regarding use of ____________ Hospital facilities for education and training opportunities,

NOW THEREFORE, in consideration of the foregoing, it is agreed as follows.

1. RELATIONSHIP. The relationship between the parties is that of two independent entities. No agent, employee or servant of ____________ Hospital shall be or shall be deemed to be an employee, agent, or servant of ___________, _____________ Schools or the State of Alabama, and no agent, employee or servant of _____________ or _____________ Schools shall be deemed to be an employee, agent or servant of _____________ Hospital, except that both parties agree to comply with privacy and confidentiality requirements of each other. _______________ Hospital will be solely and entirely responsible for the acts of its agents, employees, servants, and contractors during the performance of this agreement. ____________ will provide to ___________ Hospitala copy of student information sheet to include dates and specific rotation experience required at ______________ Hospital. ____________ will indemnify and save ________________ Hospital from any liability or damage the facility may suffer as a result of claims, demand, or costs or judgment against it arising out of the operation of this agreement.

2. FACILITIES. ____________ Hospital will provide its facilities to ____________ for the education and training of students from _____________ regarding preparation for a health career. ______________ Hospital will make available, so far as possible and reasonable, access ______________ parking for students. It is expressly understood, however, that all costs of food service and parking are to be borne by the students and are not the responsibility of ____________ Hospital. _____________ Hospital will follow internal protocol in case of injury to students during training. Cost of any such care will be the sole responsibility of the student.

3. INSTRUCTION. ______________ Hospital will provide the cooperation of its staff for instruction to ____________ students. _____________ will be responsible for oversight, guidance, grading, record keeping, and instruction of all students.

4. MATERIALS. _____________ High School will provide all students’ instructional materials and supplies at no cost to ______________ Hospital.

5. UNIFORMS. Student uniforms, shoes, and scrubs are the responsibility of the student and cost will not be borne by _____________ Hospital without mutual agreement between ______________ Hospital and student.

6. INSURANCE. ___________ will bear the sole responsibility to ensure that student professional liability insurance meets hospital requirements ($1 million per occurrence or $3 million aggregate minimum). A certificate evidencing acceptable insurance for this program will be provided upon request. _____________ has full worker’s compensation insurance as required by law.

7. RULES AND REGULATIONS. _____________ Hospital may from time to time issue non- discriminatory rules and regulations regarding this program. Such rules and regulations will be discussed with representatives from ________________ before implementation. Once implemented all such rules and regulations shall be enforced by ____________ and ____________ Hospital on students and faculty of ______________ participating in the program. ______________ Hospital has ultimate responsibility of the quality of care given to patients and thus reserves the right to refuse access to any student or faculty member of ______________ who does not meet ______________________ employee standards for safety, health, or ethical behavior. ________________ Hospital may resolve any dispute or problem situation in favor of its’ patients, or staff, or ____________ Hospital’s welfare, and restrict access of any student or faculty member of ___________ until such dispute or problem can be resolved. ___________ personnel and ___________ students shall not engage themselves in matters relating to the internal operation of _____________ Hospital. ______________ and ______________ Hospital reserve the right to evaluate and if necessary temporarily interrupt or terminate educational experiences under this agreement if the existing conditions are not conducive to good educational and patient care practices. The students will strictly abide by _______________ Hospital’s compliance policies and procedures and agrees to report any compliance issues to the appropriate parties.

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8. HEALTH CARE. Prior to acceptance for participation in this program students and faculty of ______________ shall have; a) a skin test (to be repeated annually) and, if indicated, a chest x-ray; b) immunization for diphtheria and tetanus; c) a Hepatitis B immunization unless accepted by ______________ Hospital upon submission of a notarized declination form; and d) proof of immunity to rubella, varicella, and rubeola. Students and faculty of ___________ shall be responsible for their own medical expenses. Any service provided by _____________ Hospital for the student or faculty member is the responsibility of the student or faculty member. Documents evidencing these responsibilities will be provided upon request. ______________ agrees that each participating student shall be subject to drug/alcohol screening policy in effect at _______________ Hospital during the time of the clinical experience.

9. GOVERNANCE. The laws of the State of Alabama and rules and regulations issued pursuant thereto, shall be applied in the interpretation, execution, and enforcement of this agreement.

10. DISCRIMINATION AND AFFIRMATIVE ACTION. Neither ________________ Hospital nor ______________ shall discriminate on the basis of race, color, creed, sex, national origin or ancestry, disability, or age in access to, treatment in or benefits under this agreement.

11. STUDENT/TRAINEE REQUIREMENTS. _______________ Hospital reserves the right to require the following, at its’ sole option: (Optional)

a. Each new student may be interviewed and approved by a designated representative of ______________ Hospital prior to the student’s assignment.

b. The vita and qualifications of each student are submitted.c. Each student submits documentation of skills and knowledge required by

______________ Hospital or its’ designated representative prior to placement at _______________ Hospital for supervised clinical internship.

d. A clinical rotation schedule will be provided to ______________ Hospital with student name, date, time, and hospital area/department.

12. REGULATORY AND ACCREDITATON REQUIREMENTS. ________________ Hospital and ______________ agree to comply with all applicable federal and state laws, regulations, policies, and accreditation requirements. ______________ Hospital and _____________ specifically agree to comply with all requirements set forth by the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) as required by this relationship. The students will receive training related to ____________ Hospital Exposure Control Plan for Blood borne Pathogens prior to being in the clinical setting at _______________ Hospital, as required by OSHA. The student or ________________ Hospital personnel must inform patients of the student’s presence and participation during exams, procedures, and treatments (may be verbal and/or name badge identification indicating position, title, and affiliation).

13. CONFIDENTIALITY OF INFORMATION. All patient, physician, visitor, and hospital information will be maintained in the strictest confidence. All reports, memoranda, correspondence, and notes shall be, strictly confidential and used only for the purpose in which the student or faculty is instructed. Inappropriate disclosure of confidential information by a student of faculty member will result in immediate termination of the student or faculty member from participation. ____________ Hospital will provide training on the Health Insurance Portability and Accountability Act of 1996 (HIPAA) regulations regarding confidential information prior to the commencement of any student or faculty member in the program. Each student or faculty member will meet or exceed those requirements. ____________ agrees to comply with the applicable provisions of the Federal Privacy Rule promulgated by HIPAA, as contained in 45 CFR Parts 160 and 164 (“the HIPAA Privacy Rule’). ______________ agrees not to use or further disclose any protected health information (“PHI”), as defined in 45 CFR 164.504, other than as permitted by this Agreement and the requirements of the HIPAA Privacy Rule. _____________ will implement appropriate safeguards to prevent the use or disclosure of PHI other than as provided for by this agreement. ____________ will promptly report to the facility any disclosure of PHI not provided for by this Agreement or in violation of the HIPAA Privacy Rule of which ____________ becomes aware.

14. AMENDMENTS TO AGREEMENT. All terms of this agreement shall remain in effect throughout its’ term unless the parties mutually agree, in a written amendment signed by both parties and attached to this agreement to amend or delete any provision. Any amendment or deletion from this agreement shall become effective at the time specified in the amendment of deletion. An annual evaluation of this agreement will be conducted during its’ term.

15. TERM. This agreement shall commence with its’ execution by both parties and will continue in force for a period of two years unless canceled by either party upon thirty (30) days written notice to the following addresses, which may from time-to-time be changed by the parties:

16. INTEGRATION OF UNDERSTANDINGS. This agreement is intended as the complete integration of all understanding between ______________ and _______________ Hospital and together with any amendments adopted pursuant to the agreement will comprise the entire agreement between the parties.

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17. HEADINGS. Paragraph headings are for reference only and do not constitute part of this agreement.






THIS AGREEMENT IS ENTERED INTO BY AND BETWEEN THE PARTIES THIS ________ DAY OF ____________________, 20___.

_______________________ Hospital ____________________High School

By: __________________________ By: __________________________

Title: _________________________ Title: _________________________

Address: ______________________ Address: ______________________

______________________________ ______________________________

______________________________ ______________________________(SAMPLE)

HEALTH SCIENCE CLINICAL INTERNSHIP

TIME SHEET AND JOURNAL

STUDENT NAME_______________________________ CLINICAL SITE____________________________

Timesheet Student Journal

Date__/__/__

Time In_____

Time Out____

1. Describe your responsibilities during clinical rotation.

2. List new equipment and /or procedures that you observed.

3. Will this clinical rotation help you meet your clinical objective?

4. Do you need to request a conference with the instructor regarding clinical rotation?

Date__/__/__

Time In_____

Time Out____





Date__/__/__



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Time In_____

Time Out____3. Will this clinical rotation help you meet your clinical objective?


Date__/__/__

Time In____

Time Out____





Date__/__/__

Time In_____

Time Out____





Preceptor(s) Name (Print) _______________________ Preceptor(s) Signature________________________Preceptor(s) - Please write any comments or suggestions below or on back of this form.

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CLINICAL INTERNSHIP EVALUATION OF STUDENT PERFORMANCE

Student Name_________________________ Clinical Site_______________________________ Date ________

Circle: 0= Undesirable 1= Poor 2= Fair 3= Good 4= Excellent

1. Ability to get along with others 0 1 2 3 4

2. Appearance and Professional Dress 0 1 2 3 4

3. Attendance 0 1 2 3 4

4. Dependability 0 1 2 3 4

5. Eager to learn 0 1 2 3 4

6. Positive attitude 0 1 2 3 4

7. Respectful 0 1 2 3 4

8. Willingness to work 0 1 2 3 4

9. Comments/Suggestions__________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Preceptor(s) Name (Print)________________________ Preceptor(s) Signature __________________________

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Date _________________


STUDENT CONFIDENTIALITY AGREEMENT

As a student, you may have access to what this agreement refers to as “confidential information.” The purpose of this agreement is to help you understand your duty regarding confidential information in the healthcare setting.

Confidential information includes patient’s personal and medical information, employee/volunteer/student information, financial information, other information relating to healthcare agency, and information proprietary to other companies or persons providing services to agency or patients/employees. You may learn of or have access to some or all of this confidential information through a computer system or through your rotational/observation activities.

Confidential information is valuable and sensitive and is protected by law and by strict agency policies. The intent of these laws and policies is to ensure that confidential information will remain confidential – that is, that will be used only as necessary to accomplish the organization’s mission. As a student, you are required to conduct yourself in strict conformance to applicable laws and agency policies governing confidential information. Your principal obligations in this area are explained below. You are required to read and to abide by these duties. The violation of any of these duties will subject you to discipline, which might include, but is not limited to, termination of rotation/observation experience and legal liability.

As a student, you understand that you will have access to confidential information that may include, but is not limited to, information relating to:

Patients (such as medical records, conversations, admittance information, patient financial information, etc.) Employee/volunteers/students (such as salaries, employment records, disciplinary actions, etc.) Agency information (such as financial and statistical records, strategic plans, internal reports, memos, contracts, peer review

information communications, proprietary computer programs, source code, proprietary technology, etc.) Third-party information (such as computer programs, client and vendor proprietary information, source code, proprietary

technology, etc.)

Accordingly, as a condition of and in consideration of your access to confidential information, you promise that:

1. You will use confidential information only as needed to perform your legitimate duties as a student. This means that among other things, that:

a. You will only access confidential information for which you have a need to know.b. You will not in any way copy, release, sell, loan, review, alter, or destroy and confidential information except as

properly authorized within the scope of your professional activities affiliated with agency.c. You will not misuse confidential information or carelessly care for confidential information.

2. You will safeguard and will not disclose any access code or any other authorization you have that allows you to access confidential information.

3. You accept responsibility for all activities undertaken using your access code and other authorization.

4. You will report activities by any individual or entity that you suspect may compromise the confidentiality of confidential information. Reports made in good faith about suspect activities will be held in confidence to the extent permitted by law, including the name of the individual reporting the activities.

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5. You understand that your obligations under this Agreement will continue after termination of your rotation/shadowing experience. You understand that your privileges hereunder are subject to periodic review, revision, and if appropriate, renewal.

6. You understand that you have no right or ownership interest in any confidential information referred to in this agreement. Agency may at any time revoke your access code, other authorization, or access to confidential information. At all times during your rotation/observation experience, you will safeguard and retain the confidentiality of all confidential information.

7. You will be responsible for your misuse or wrongful disclosure of confidential information and for your failure to safeguard your access code or other authorization access to confidential information. You understand that your failure to comply with this Agreement may also result in your loss of employment with agency.

_______________________________________________ ________________________Student Signature Date

_______________________________________________ ________________________Parent/Legal Guardian Signature Date


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EDUCATION AND TRAINING INTERNSHIP

Education and Training Internship is a one-credit course for students who are interested in pursuing careers in the education field. This course provides students with a context in which they can make a personal assessment of their commitment to pursue a teaching, professional support services, or educational leadership career. Students are assigned Internships in which they participate in situations in an educational environment. The Internship is supervised by a Family and Consumer Sciences teacher who holds a Class B or high certification.

Definitions

Education and Training Internship Supervisors Supervising Teacher : is the Family and Consumer Sciences teacher who teaches the Education and

Training Internship course.

Internship Supervisor : is the teacher, administrator, or professional support services staff member who supervises and mentors the intern in the appropriately assigned educational setting.

Education and Training Internship Requirements Prerequisites : Students must have taken the following courses prior to placement in the Internship:

Education and Training, Teaching I and Teaching II; or Education and Training, Early Childhood Education I and Early Childhood Education II; or Education and Training and Educational Leadership; or Education and Training and Professional Support Services in Education.

Education and Training Internship Course Requirements : Students must be enrolled in the Education and Training Internship course and will meet a minimum of once per week with the Supervising Teacher managing the intern to acquire additional content knowledge and skill, discuss experiences related to the Education and Training Internship, complete any required paperwork, and receive Professional Work Sample Portfolio assignments.

Professional Work Sample Portfolio (PWS) : is a snapshot of the interns work in the Education and Training Internship course. The PWS consist of four components (1) planning, (2) implementation, (3) reflection, and (4) evaluation of student learning.

Intern Selection/Qualifications : Education and Training Internship candidates must: Have successfully completed the prerequisite courses. Be enrolled in grades 11-12. Have completed the application process. Be selected for participation by the Supervising Teacher.

Roles and Responsibilities : Education and Training Internships require time, commitment and collaboration of the following partners:

Interns are responsible for conducting themselves in a professional manner. They must maintain a Professional Work Sample Portfolio.

Parents/Guardians provide ongoing support to the intern and the Education and Training Internship. They are responsible for the conduct and attendance of the intern. Parents/Guardians must provide transportation for the intern to and from the Internship site.

Supervising Teacher provides assistance in locating the most beneficial Internship site for each intern, ongoing supervision of the intern, and manages all requirements of the Internship and works collaboratively in designing the learning experiences with the Internship Supervisor.

Intern Supervisor provides opportunities for students to complete Internship activities, gain 60

valuable experience in the field of Education, and evaluates the intern’s performance. Appropriate Placement is an actual educational setting that provides the intern with the

maximum opportunity to learn and gain experience in the field of education. All Education and Training Internships must relate to the intern’s career objective/pathway/program.

Credits Earned One credit is earned for the completion of Education and Training Internship course.

Hour Requirements : Interns must successfully complete 140 hours of instructional time that combines activities required by the Supervising Teacher and the Internship Supervisor.

Supervision Teacher Requirements: must make an on-site visit to the Internship Site at least twice a month and maintain all required documentation for each intern participating. The Professional Work Sample Portfolio is used to document the intern’s mastery of learning and for determining grades.

Placement Restrictions or Limitations : Interns may not be placed where immediate family members will be acting as the Internship Supervisor.

Required Documentation and Forms : The following documentation must be maintained and on file by the Supervising Teacher for each participating intern during the Education and Training Internship.

Prior to Enrollment: Must declare a career objective related to Education and Training Cluster Must have completed the Education and Training Internship Application Must complete an interview with the Education and Training Internship teacher

Upon Placement of Student: Education and Training Internship Agreement Proof of Insurance Emergency Contact Form Intern Attendance Record Record of Supervising Teacher Intern Visits Other Forms as required by the Local Education Agency

Upon Completion of the Internship: Intern Evaluation of Education and Training Internship Experience Intern Follow-up Form Copy of Professional Work Sample Portfolio Evaluation

NOTE: These forms must be kept on file a minimum of 3 years.

WagesEducation and Training Internships are unpaid work-based experiences.

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(SAMPLE)

Education and Training InternshipAPPLICATION FOR ENROLLMENT

PLEASE PRINT OR KEY ALL INFORMATION REQUESTED EXCEPT SIGNATURE.

Date ___________________________________

Name Last First Middle Maiden

Present Address

Number Street City State Zip

Home Telephone ( ) Cell Telephone ( )

Age Date of Birth - -

Do you have a driver’s license? Yes No Do you have access to a car/other mode of transportation? Yes No

Education and Training Courses Completed or Enrolled In:

Career Objective: 1st Choice_____________ 2nd Choice____________________ 3rd Choice _________________

Parent/Guardian Name(s) Business or Cell Phone ( ) Parent/Guardian Address

Number Street City State Zip

Indicate the type of educational setting in which you prefer to work: (Example: early childhood education, elementary education, middle school education, secondary education, band teacher, career tech, physical education teacher, educational leadership, etc.)

First Choice____________________________ Second Choice __________________________

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Do you intend to further your formal education after high school? Yes No

Are you under a doctor’s care? Yes No Do you have any health problems that would interfere with your regular attendance on a job? Yes No

If yes, please explain:_____________________________________________________________________________________

___________________________________________________________________________________________

List as references the names of three teachers who can attest to the quality of your work. One must be your current or previous occupational teacher.

1. _________________________________ (Career and Technical Education Teacher)

2. _________________________________

3. _________________________________

To the intern:

The Education and Training Internship provides an opportunity to be considered for an internship in your school system. When you enroll in the Education and Training Internship, you indicate that you are sincerely interested in putting forth your best efforts to receive an Internship experience. If you accept this responsibility, please sign in the space provided.

Student Signature ________________________________________ Date _______________________________

To the Parent/Guardian:

Do you consent to your child entering the Education and Training Internship, providing transportation, and agree to cooperate with the school and the Education and Training Internship site in making the training and education of the greatest possible benefit to your child? If so, please indicate your support and approval with your signature.

Parent/Guardian Signature: __________________________________ Date ______________________________

To Be Completed By Supervising Teacher.

Current Attendance Record: No. Absences ________ No. Tardies ____________ Current Disciplinary Record: Total Reports ________ Cumulative GPA: ________

List Career and Technical Occupational Courses that determine student’s eligibility for participation:

1. ____________________________________ 3. ________________________________

2. ____________________________________ 4. ________________________________

Verified By______________________________________ (Counselor/School Administrator/ Supervising Teacher)

Status of Application: Pending Approved Not Approved

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EDUCATION AND TRAINING INTERNSHIPINTERVIEW PRACTICES

The objective during the interview is to convince the interviewer that you are the student to be selected for the Education and Training Internship. This can be accomplished by demonstrating maturity, self-assurance, poise, interest, and knowledge of what is expected in a business situation.

Do1. Be prepared.2. Arrive on time; telephone if you are unavoidably delayed.3. Stress your qualifications and interest for the Internship.4. Be businesslike and brief.5. Provide requested information; have up-to-date credentials.6. Let the interviewer take the lead in the conversation.7. Talk in terms of training, rather than saying, “I’ll take anything.”8. Make certain you understand what is required in the internship setting.9. Dress appropriately.

10. Act natural.11. Listen very carefully to the interviewer.12. Ask appropriate questions.13. Make yourself understood.14. Describe your potential service for the Internship.15. Know reasons for entering your profession.16. Get telephone numbers, names, and addresses for follow-up purposes.17. Thank the interviewer as you leave.18. Become knowledgeable of the Internship.19. Exhibit good eye contact.20. Write a follow-up letter.

Don’t1. Play with articles of clothing during the interview.2. Wear/use personal communication devices during the interview (cell phones, pagers, etc.)3. Smoke or chew gum during the interview.4. Interrupt the interviewer.5. Criticize former employers.6. Make salary the main theme of your conversation.7. Mention your personal, domestic, or financial problems.8. Freeze or become tense.9. Be late or miss your interview.

10. Present exaggerated appearance.11. Talk too much or too little.12. Try to be clever or funny.13. Make elaborate promises.14. Become emotional.15. Become impatient.16. Over-emphasize rewards.17. Prolong interview.18. Suggest how the employer should run the business.19. Take anyone to the interview with you.

(SAMPLE)EDUCATION AND TRAINING INTERNSHIP

STUDENT INTERVIEW QUESTIONS(For Student Selection)

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1. What do you believe is the purpose of the Education and Training Internship?

2. Why do you want to enroll in the Education and Training Internship?

3. Have you ever been employed before? If so, describe your job.

4. What are your plans following high school? Have you considered additional training?

5. In what ways will the Education and Training Internship help you?

6. Is there any reason why you could not participate three (3) hours weekly next year at the Education and Training Internship site during the school day? What are your plans to participate in activities during your final year at high school?

7. Are you currently a member of a student organization? Why? Why not?

8. What subjects do you find most enjoyable?

9. What special training would you expect to receive from the Education and Training Internship?

10. Where did you first hear about the Education and Training Internship?

11. What do you want to do to earn a living?

12. How do you learn outside of the classroom?

13. Are you willing to work voluntarily in order to gain work experience and a future job reference?

14. What courses do you plan to take next year?

15. What are your arrangements for transportation?

16. Would you change your appearance to become an intern? (cut hair, no nail color, short nails, no miniskirts, remove earring, etc.)

17. Do you have a preference of where you would like to perform your Education and Training Internship?

18. What is your philosophy of education?

(SAMPLE)POTENTIAL EDUCATION AND TRAINING INTERNSHIP SITE

EVALUATION CHECK SHEET(Completed by Supervising Teacher Prior to Internship Assignment)

Potential Internship Site_______________________ Internship Supervisor___________________

Address________________________________________ Telephone________________________

Date of Interview_________________ Person Interviewed________________________________

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Directions: After reading the questions below, place a check () in the appropriate column for your response.

Yes No

Does the attitude of the Internship Supervisor appear to be conducive to working with the school during the Internship?

Will the Internship Supervisor agree to allow the intern to participate in a variety of teaching experiences during the internship?

Will the equipment and facility be satisfactory?

Is the Internship Supervisor willing to work with the Supervising Teacher to develop a training agreement for a specific educational career objective?

Does the potential Internship site Internship Supervisor’s morale seem conducive to satisfactory relationships for interns?

Is the potential for the instructional classroom of the Internship site appear satisfactory?

Is the Internship site satisfactorily located?

Did the Internship Supervisor ask to see a transcript or to be provided with documentation of acceptable academic performance and attendance?

Is the Internship Supervisor willing to cooperate with the Education and Training Internship training process?

Will the Internship Supervisor provide various tasks upon reaching the proficiency level required for satisfactory performance in education?

(Over)Yes No

Is the Internship Supervisor willing to work with the intern a minimum of three (3) hours per week?

Will the Internship Supervisor objectively evaluate the educational competencies demonstrated during the Internship?

Is the Internship Supervisor willing to work with the intern during the school day?

Is the Internship site within reasonable travel distance of the school?

Does the Internship site meet the criteria as outlined in the Work-Based Learning Manual?

Comments: ____________________________________________________________________67

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

Signed: _____________________________________

Date: _______________________________________


INTERVIEW EVALUATION FORM

Student Interviewed: __________________________ Career Objective/Pathway: __________________

Above Average Average Poor

Appearance

Personality

Desire to be enrolled in the program

Concept of program’s purpose

Summary of student’s interests, abilities, and adaptability relative to career objective:

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Student’s plans following high school:

Work experience:

Reaction when asked if he/she would change personal appearance in order to become an intern:_____________

Reaction to student organization:

Possible Education and Training Internship Sites:

Comments:

(SAMPLE)ORIENTATION TO THE EDUCATION AND TRAINING INTERNSHIP SITE

(Completed by Supervising Teacher)

Intern’s Name__________________________________________ Date _________________

Internship Site________________________ Supervising Teacher _____________________________

Instructions: Prior to the initial visit to the Internship site, check each item as it is discussed with the intern.

A. School Orientation

_____ 1. Give intern copies of printed materials (handbook, brochures, etc.)._____ 2. Discuss school policies and procedures regarding:

( ) Hours of operation/work ( ) Appropriate dress and grooming ( ) Safety rules ( ) Emergency procedures ( ) Absentee procedures ( ) Parking ( ) Arrival procedures ( ) Departure procedures ( ) Breaks ( ) Daily schedules ( ) Presence of substance abuse

_____ 3. Identify Internship Supervisor.

B. Classroom Orientation

_____ 4. Describe intern’s responsibilities._____ 5. Explain the importance of the student’s responsibilities to the school system.

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C. On-Site Visit

_____ 6. Introduce intern to Internship Supervisor._____ 7. Describe the classroom procedures for Internship site._____ 8. Show intern her/his work space.

___________________________________________________ (Supervising Teacher) (Date)

___________________________________________________ (Intern) (Date)

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(SAMPLE)EDUCATION AND TRAINING INTERNSHIP TRAINING AGREEMENT

Intern’s Name _______________________________________ Birth Date ____________ Age

Intern’s Address ___

Telephone ____________________ Cell Phone _________________ E-mail

Educational Career Objective/Pathway

School Name ________________________________________ System

Internship Site __________________________________ Internship Telephone

Internship Site Address _____

Supervising Teacher ________________________ Internship Supervisor

Date Internship Period Begins ______________________________ Ends

This Internship agreement briefly outlines the responsibilities of the intern, parents, Internship Supervisor employed by the participating School, and the Supervising Teacher. The school or mentor may remove a student upon 30 days written notice or immediately with cause.

Parent/Guardian1. Approves and agrees that the intern may participate in the Education and Training Internship.2. Encourages the intern to effectively carry out the requirements and all components of the internship.3. Assumes responsibility for the conduct and attendance of the intern.4. Provides transportation for the intern to and from the Internship site.5. Holds the school, Supervising Teacher and Education and Training Internship site harmless for risks associated with transportation and

indirectly monitored activities.

Intern1. Complies with the rules and regulations of the Education and Training Internship site.2. Adheres to all policies and regulations as set forth by school administration and the Supervising Teacher.

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3. Shall, at the intern’s expense, take required TB tests as required by the local education agency.4. Shall have and maintain liability insurance coverage while participating in the Education and Training Internship site.5. Is an active member of the student organization Family, Career, and Community Leaders of America (FCCLA) and Future Teachers of

Alabama (FTA).6. During the school day, Monday – Friday, completes the 140 hours required for the Education and Training Internship.7. Maintains documentation of the number of hours the student has worked at the Education and Training Internship site.8. Shall not perform duties in which he/she has not received instruction.9. Shall keep regular attendance at school and at the Education and Training Internship site.10. Any student failing to comply with policies, rules and regulations is subject to dismissal from the program.11. Shall be responsible for transportation to and from the Education and Training Internship site.12. Shall not displace adult workers who can perform such work as assigned in the Education and Training Internship site.

Supervising Teacher1. Secures appropriate Education and Training Internship site determined by the intern’s career objectives/pathway.2. Works with the Internship Supervisor in developing an Internship Agreement Plan for the intern.3. Visits the Education and Training Internship site at least twice per month to confer with the Internship Supervisor and intern; verifies that

intern’s duties correlate with prior instruction; observes working conditions; helps develop progressive skill-building activities; observes and evaluates intern’s progress; and resolve questions, issues, or concerns.

4. Counsels the intern about his/her Internship experience, behavior, attitude, academics, etc.5. Terminates the Internship when it serves the best interest of the intern as determined in collaboration with the Internship Supervisor.6. Determines the intern’s final grade for the Internship.7. Reinforces Internship with related classroom instruction.

Internship Supervisor (School Internship Supervisor Representative)1. Recognizes that the intern is enrolled in an Education and Training Internship designed to prepare him/her for a career in an Education

and Training or related occupation.2. Provides supervision and instruction in each of the applicable tasks listed on the Professional Work Sample Portfolio to assist the intern in

acquiring those competencies necessary for success in the educational career objective.3. Evaluates and documents intern’s progress.4. Adheres to the number of hours an intern may work; child labor; and all other federal, state, and local laws pertaining to student

employment.5. Provides training to the student for the time required for the Education and Training Internship.6. Completes and returns the Education and Training Internship Evaluation to the Supervising Teacher on the required date.


Name and Title (i.e. 504 Coordinator or Name and Title (i.e. 504 Coordinator or

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Title IX Coordinator)Address Telephone NumberE-mail Address

Title IX Coordinator)Address Telephone NumberE-mail Address

All Parties Adhere to the following1. Confidential Policy for Intern, Supervising Teacher, and Internship Supervisor : All student and visitor information will be maintained in

the strictest confidence. All reports, memoranda, correspondence, parent conferences and notes shall be, strictly confidential and used only for the purpose in which the student intern is instructed. Inappropriate disclosure of confidential information by an intern will result in immediate termination of the intern from participation in the Education and Training Internship. ____________ School will provide training on the Family Educational Rights and Privacy Act (FERPA) regulations regarding confidential information prior to the commencement of any intern beginning the Internship program. Each intern will meet or exceed those requirements. The intern agrees to comply with the applicable provisions of the Federal Privacy Rule promulgated by FERPA. The intern agrees not to use or further disclose any information protected by FERPA. The Internship Supervisor will implement appropriate safeguards to prevent the use or disclosure of confidential materials other than as provided for by this agreement. Any disclosure of confidential information not provided for by this Agreement or in violation of the FERPA Privacy Rule will be promptly report to the Supervising Teacher.

Intern_____________________________________

Parent/Guardian_____________________________

Supervising Teacher__________________________

Internship Supervisor_________________________

School Administrator_________________________

Internship Site Administrator___________________

Date

Date

Date

Date

Date

Date

_________________

_________________

_________________

_________________

_________________

_________________

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DAILY SCHEDULE HOUR REPORT

Intern________________________________________Intership Site__________________________________Supervising Teacher_____________________

Month_______________ Year______ Supervising Teacher’s Initials Month_____________ Year_______ Supervising Teacher’s Initials

Number of Hours Worked

Total Hours Worked

Number of Hours Worked Total Hours Worked

Week Sun Mon Tues Wed Thurs Fri Sat Week Sun Mon Tues Wed Thurs Fri Sat

1X X

1X X

2X X

2X X

3X X

3X X

4X X

4X X

5

X X 5

X X

Total Total

D.

Month_______________ Year______ Supervising Teacher’s Initials Month_____________ Year_______ Supervising Teacher’s Initials

Number of Hours Worked

Total Hours Worked

Number of Hours Worked Total Hours Worked

Week Sun Mon Tues Wed Thurs Fri Sat Week Sun Mon Tues Wed Thurs Fri Sat

1X X

1X X

2X X

2X X

3X X

3X X

4X X

4X X

5

X X 5

X X

Total Total

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CUMULATIVE RECORD

Aug Sept OctNov Dec

Jan Feb March April May

Hours This Month

Hours Y-T-D

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(SAMPLE)Education and Training Internship

Proof of Insurance and Emergency Contact Form

Insurance Information

Please note the intern’s health insurance coverage below:

Name of Insurance Plan:__________________________________________________________

Insurance Card ID/Policy #________________________________________________________

Expiration Date:________________________________________________________________

Please attach photocopy proof of insurance.

Emergency Contact Information

Please provide the name, address, and telephone number of two persons who may be contacted in the event of an emergency:

Name and Relationship:__________________________________________________________

Street Address:_________________________________________________________________

______________________________________________________________________________

Telephone:_________________________Cell: _______________________________________

E-mail:________________________________________________________________________

Name and Relationship:__________________________________________________________

Street Address:_________________________________________________________________

______________________________________________________________________________

Telephone:_________________________Cell: _______________________________________

E-mail:________________________________________________________________________

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(Sample)EDUCATION AND TRAINING INTERNSHIP SUPERVISING TEACHER’S

MONTHLY TRAVEL LOG

Name ____________________________ Month ______________________ Year __________

DATE

FROM

TO

PURPOSE OF TRAVEL

CONTACT PERSON

MILEAGE

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Submit this form monthly to the designated LEA official.(SAMPLE)

Education and Training InternshipRecord of Supervising Teacher Site Visits

(Teaching and Training)(Early Childhood Education)

Intern____________________________ Internship Supervisor_________________________

The Internship Supervising Teacher will visit the intern at the Education and Training Internship site at least twice a month. The following document is designed for the Supervising Teacher to use in recording site visits. The following “Activity Codes” are suggested for a quick reference of the activities observed during the visit.

Activity Code Purpose of Visit

I Observing InternL Observing LearnersA Aide Activity (Stapling, Grading, etc.)R Preparing Instructional Resources/Bulletin Boards W Working with LearnersTS Teaching Small GroupTL Teaching Large Group/ClassSG Supervising Small Group

SLG Supervising Large Group/ClassO Other:

Date Code Comments

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(SAMPLE)Education and Training Internship

Record of Supervising Teacher Site Visits(Administration and Administrative Support)

(Professional Support Services)

Intern____________________________ Internship Supervisor_________________________

The Internship Supervising Teacher will visit the intern at the Education and Training Internship site at least twice a month. The following document is designed for the Supervising Teacher to use in recording site visits.

Date Comments

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(SAMPLE)Evaluation of Education and Training Internship

Teaching and Training/Early Childhood Education

Intern________________________________________________________________________________

Internship Supervisor___________________________________________________________________

Grading Period_________________________________ From__________________ To _____________

Evaluation Due Date_______________ Dates of Absences/Tardies_______________________________

Directions: Circle the appropriate rating, 0 Low, 4 High, NA (Not applicable for grading period), for each of the topics listed below.

TOPICI. Human Relations

Cooperative/Works Well with Others/Willing to Do Less Desirable Tasks

0 1 2 3 4 NA

Patient/Tolerant/Tactful 0 1 2 3 4 NAAccepting of Students 0 1 2 3 4 NAFriendly/Self Confident 0 1 2 3 4 NA

II. Communication SkillsVoice Projection 0 1 2 3 4 NAEnunciation 0 1 2 3 4 NAGrammatical Proficiency 0 1 2 3 4 NAHandwriting is Legible 0 1 2 3 4 NAFollows Instructions 0 1 2 3 4 NAApplies Active Listening Skills to Obtain and Clarify Information

0 1 2 3 4 NA

III. Professional Attitude/AbilitiesExcellence Attendance/Punctual 0 1 2 3 4 NAShows Initiative/Enthusiasm 0 1 2 3 4 NAResponsible/Exhibits Good Work Habits 0 1 2 3 4 NASeeks Suggestions 0 1 2 3 4 NAAppropriate Appearance 0 1 2 3 4 NAIntegrity 0 1 2 3 4 NAExercises Persistence 0 1 2 3 4 NAObserves District Polices 0 1 2 3 4 NAShows Increasing Knowledge of Job 0 1 2 3 4 NA

IV. Classroom ManagementFirm/Consistent 0 1 2 3 4 NAUses Effective Solutions/Flexible/Adaptable 0 1 2 3 4 NAMaintains Pleasant Classroom Environment 0 1 2 3 4 NAOrganized/Effective Time Manager 0 1 2 3 4 NADemonstrates Proper Responses 0 1 2 3 4 NA

V. Planning for TeachingDemonstrates Command of the Subject 0 1 2 3 4 NA

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Plans and Organizes Lessons 0 1 2 3 4 NARelates Subject Matter to Level of Students 0 1 2 3 4 NAExhibits Concern for Individual Differences 0 1 2 3 4 NA

VI. Executing Lesson PlansMotivates 0 1 2 3 4 NAStates Purpose 0 1 2 3 4 NAUses Effective Questioning Skills 0 1 2 3 4 NAPromotes Critical Thinking/Incorporates Higher Level Strategies 0 1 2 3 4 NA

Internship Supervisor’s Signature: __________________________ TOTAL SCORE ______________

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Administration and Administrative Support

Intern _______________________________________________________________________________







0 1 2 3 4 NA



0 1 2 3 4 NA

Interprets Tables/Charts/Figures to Support Written and Oral Communications

0 1 2 3 4 NA


IV. Instructional LeadershipDetermines strategies that foster a positive organizational structure and learning culture for accelerating student achievement and teacher morale.

0 1 2 3 4 NA

Assessed school demographics and student assessment data to determine instructional goals that meet individual student needs 0 1 2 3 4 NA

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and interests.Identifies evidenced-based instructional practices that lead to student achievement. 0 1 2 3 4 NADetermines instructional resources and technology used for meeting organizational and instructional goals. 0 1 2 3 4 NADetermines how instructional programs and course offerings are planned and implemented. 0 1 2 3 4 NA

V. Managerial LeadershipIdentifies strategies for enhancing personnel performance and motivation.

0 1 2 3 4 NA

Determines factors involved in managing school building operations.

0 1 2 3 4 NA

Determines how to secure adequate resources to meet organizational objectives.

0 1 2 3 4 NA

Identifies methods used to evaluate faculty and staff. 0 1 2 3 4 NAEvaluates facility plans to meet organizational goals and to ensure safety and security of students and personnel. 0 1 2 3 4 NADetermines the impact of technology on the administration of educational programs. 0 1 2 3 4 NA

VI. Political LeadershipExhibits public relations skills to increase internal/external customer/client satisfaction. 0 1 2 3 4 NAIdentifies stakeholder partnerships to meet organizational objectives.

0 1 2 3 4 NA

Determines educational resources used to respond to community issues.

0 1 2 3 4 NA

Determines strategies for negotiating within political, social, economical, legal, and cultural contexts to meet organizational objectives.

0 1 2 3 4 NA


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Professional Support Services

Intern________________________________________________________________________________







0 1 2 3 4 NA



0 1 2 3 4 NA

Interprets Tables/Charts/Figures to Support Written and Oral Communications

0 1 2 3 4 NA


IV. Support ServicesAnalyzes tasks and responsibilities performed by professional support services staff to enhance student achievement and meet instructional goals.

0 1 2 3 4 NA

Distinguishes among the types of professional support service careers to determine the area of interest. 0 1 2 3 4 NA

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Evaluates the impact of professional support services on education.

0 1 2 3 4 NA

Assesses the ways technology impacts professional support services.

0 1 2 3 4 NA

Explains principles of support and service processes. 0 1 2 3 4 NAV. Assessment

Determines needs of students by employing strategies and techniques used by professional support services staff. 0 1 2 3 4 NAEvaluates assessment tools used by professional support services staff.

0 1 2 3 4 NA

Explains assessment results to prepare stakeholders to participate in developing an action plan for education. 0 1 2 3 4 NA

VI. Support and InterventionIdentifies methods to stimulate stakeholders to identify interests and needs of students. 0 1 2 3 4 NAEvaluates resources available to stakeholders to participate in developing an action plan for education. 0 1 2 3 4 NAConstructs personal action plans for educational success. 0 1 2 3 4 NAConstructs group action plans for educational success. 0 1 2 3 4 NACoordinates support services to meet needs of students. 0 1 2 3 4 NAAssesses benefits and potential resources for intervention. 0 1 2 3 4 NAIdentifies skills to advocate the need of increased resources to meet need of learners. 0 1 2 3 4 NA


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(SAMPLE)

Education and Training Internship STUDENT FOLLOW-UP FORM

Intern:________________________________________________________________ Phone:______________ (Last) (First) (Middle)

Graduation Date: ______________

Current Address:_____________________________________________________________________________ (Street) (City) (State) (Zip Code)

Post High School Endeavors: (Check One)

( ) Not Certain ( ) Additional Education ___________________ Area of Study ____________________

( ) Military ________________________ ( ) Immediate Employment ____________________________ Branch Employer

Please provide the name of a relative or friend that will most likely be at the following address three years from now:

Name: _______________________________________ Phone:______________ Relation: (Last) (First) (Middle)Address: (Street) (City) (State) (Zip Code)

ONE YEAR AFTER GRADUATIONWhat is your current name and address?

Name:______________________________________ Phone:______________ Marital Status: (Last) (First) (Middle)

Address: (Street) (City) (State) (Zip Code)

Are you employed? ___ Yes ___ No If yes, please provide the following information:

Employer: ________________________________________________________________

Employer’s Address: _______________________________________________________

Job Title: ________________________________________________________________

Length of Time At Job: _____________________________________________________

_____ Part-time _____ Full-time Approximate Gross Salary: $ __________________

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If you are not employed, are you seeking work? ___ Yes ___ No

Which of the following assisted you most in securing your present job?

___ Academic Teacher ___ Friend

___ Teacher-Coordinator ___ Want Ad

___ Counselor ___ Internet

___ Parent ___Other

___ Relative

Rate the academic and Career and Technical counseling you received:

___ Good ___ Average ___ Poor ___ None

Please list any additional comments/recommendations you feel may be useful in planning a better Education and Training Internship program:

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(SAMPLE)INTERN’S SELF EVALUATION OF EDUCATION AND TRAINING INTERNSHIP

Intern’s Name ________________________________________________________________________

Education and Training Internship Site ____________________________________________________

No. of Weeks at Internship Location ______________________________________________________

Internship Supervisor’s Name ___________________________________________________________

1. Duties 2. Is your internship what you expected it to be?

Explain: 3. Has your Internship Supervisor been providing guidance/instructions? ( ) Yes ( ) No If yes, Internship supervisor’s name: 4. Were you given ample instruction when you started the internship? ( ) Yes ( ) No 5. Have you been given helpful instruction when needed? ( ) Yes ( ) No6. Has the staff at Internship site been friendly and courteous? ( ) Yes ( ) No 7. Were school rules and regulations explained clearly? ( ) Yes ( ) No 8. Please rate your Internship Supervisor on the following points:

Good Average PoorIntroduced you to all staff in the school/departmentExplained changes which affect youInterested in you and your internship performanceFollowed up counseling

9. What were the working conditions in your school? Explain:_______________________________________ 10. What can you suggest that would better the Internship conditions at your Education and Training Internship

site for future education interns? __________________________________________________________________

11. General comments to evaluate your Education and Training Internship site not included in the above questions: _____________________________________________________________________________________________________________________________________________________________________

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SUPERVISED AGRICULTURAL EXPERIENCE (SAE)

DefinitionSupervised Agricultural Experience (SAE) is a work-based learning opportunity that allows students with a career objective in Agriscience to gain experience and apply what is learned in the classroom, laboratory or training site to real-life situations. The experience is supervised by an Agriscience teacher including those holding level and specialty area certificates.

Purpose/Objective: Career Exploration/ApplicationThe objective of the SAE is to provide students the opportunity to gain experience in agricultural fields for which they have a career interest and objective.

PrerequisitesThere is no prerequisite.

Related InstructionStudents must be enrolled in an Agriscience course related to the student’s career objective.

Student Selection/QualificationsAll students enrolled in an Agriscience course are encouraged to participate in SAE.

Roles and ResponsibilitiesSAEs require time, commitment, and collaboration of the following partners:

Students are responsible for maintaining their SAE record book. Parents/Guardians provide ongoing support to the student. Parents must provide

transportation to the SAE site if applicable. Agriscience Teachers provide ongoing supervision to the student and integrate the

student's worksite experience with learning at school. Business and community partners may provide opportunities for students to complete the

SAE.

Appropriate PlacementAll SAE opportunities must relate to the student’s career objective and adhere to all federal and state Child Labor Laws. Credits EarnedNo credit will be earned.

Hour RequirementsHours are facilitated by the sponsoring Career and Technical Education teacher.

Supervision/Coordination RequirementsClose supervision is necessary for successful implementation of a SAE. Agriscience teachers are responsible for the educational progress of their students.

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Placement Restrictions or LimitationsStudents may not work in any hazardous occupation as defined by state and federal Child Labor Laws.

Required Documentation and FormsThe SAE record book must be completed and on file with the Agriscience teacher for each student participating in SAE.

WagesThe SAE is normally a non-paid work experience however students may receive pay for their work.

Insurance CoverageNot Applicable.

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HEALTH SCIENCE CAREER SHADOWING

DefinitionHealth Science Career Shadowing is a structured component of the Career and Technical Education Health Science curriculum that provides a supervised observational experience in an approved health care setting. Health Science Career Shadowing is designed to be completed in a hospital, extended care facility, rehabilitation center, medical office, imaging laboratory, or other approved health care facility. Career Shadowing experiences are integrated within specific Health Science courses that allow the student to observe technical skills learned in the classroom. This experience is directly supervised by the Health Science teacher or a designated preceptor.

Purpose/Objective: Occupational PreparationHealth Science Career Shadowing provides an opportunity for students in grades 8–12 to gain knowledge by observing previously learned theory in an actual health care setting. These experiences are uniquely designed to meet course content standards through supervised experiences and observations, which are coupled with related classroom instruction.

PrerequisitesPrior to placement in a shadowing experience each LEA shall ensure that a Health Science Career Shadowing Training Agreement is secured. Parent signature on training agreement is required in order to participate in shadowing experience.

Related InstructionStudents must be enrolled in a Health Science course. Health Science Career Shadowing must be performed during normal school hours. The Health Science teacher is responsible for identifying the approved healthcare facility and placement of the student.

Student Participation/QualificationsStudents participating in Health Science Career Shadowing must:

Be enrolled in Grades 8-12. Be physically and mentally capable of observing and maintaining attention while

shadowing. Be in good academic standing and have an acceptable discipline record as determined by

the Health Science Teacher.

Roles and ResponsibilitiesHealth Science Career Shadowing requires time, commitment, and collaboration of the following partners:

Students must arrive at the healthcare facility at the appropriate time and in the appropriate dress. Students must comply with the rules and regulations of the school district, school, and training facility.

Parents/Guardians should provide ongoing support to the student and assume the responsibility for the conduct of the students.

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Health Science teachers shall identify the healthcare facility and placement of students based on their area of interest.

Appropriate PlacementThe Health Science Career Shadowing experience provides an opportunity for a student to observe in the healthcare setting and gain a broader perspective and understanding of various healthcare occupations.

Credits EarnedCredit is earned for the specific Health Science course for which the student is enrolled.

Hour RequirementsHours are assigned by the sponsoring Health Science teacher.

Required Documentation and formsThe following documentation or forms must be completed and placed in the student file with the Health Science teacher for each student participating in Health Science Career Shadowing. The documents and forms must be kept on file a minimum of 5 years.

Health Science Career Shadowing Training Agreement Student Confidentiality Statement Other Forms/Documents as required by the Health Science Teacher, Local Education

Agency, or Healthcare Agency

WagesHealth Science Career Shadowing experiences are unpaid.

Insurance Coverage/ImmunizationsAll participants in Health Science Career Shadowing must provide:

Current health insurance coverage Automobile liability insurance (if student provides own transportation) Other Forms/Documents as required by the Health Science Teacher, Local Education

Agency, or Healthcare Agency

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CAREER SHADOWING TRAINING AGREEMENT

Student’s Name _______________________________________ Birth Date ____________ Age __________________Student’s Address _________________________________________________________________________________Telephone ____________________ Cell Phone _________________ E-mail __________________________________Mother’s Name _________________________ Telephone _____________________ Cell Phone _________________Father’s Name __________________________ Telephone _____________________ Cell Phone _________________Current Career Objective/Pathway ______________________ School System _________________________________School Name _______________________________________ Address ______________________________________Healthcare Agency Shadowing _________________________________ Telephone ____________________________Healthcare Agency Address _________________________________________________________________________Health Science Teacher ____________________________ Date of Career Shadowing __________________________

This training agreement briefly outlines the responsibilities of the student, parents, teacher, and healthcare agency/preceptor.

Parent/Guardian1. Approves and agrees that the student may participate in the Health Science Career Shadowing experience.2. Encourages the student to effectively carry out the requirements and all components of the program.3. Assumes responsibility for the conduct and attendance of the student.4. Responsible for transportation arrangements for the student to and from the healthcare site (if transportation not

provided by school system) and will be responsible for any liability involved.5. Holds the school, school system, Health Science teacher and training agency harmless for risks associated with

transportation and indirectly monitored activities (e.g., Career Shadowing).

Student6. Complies with the rules and regulations of the healthcare site.7. Adheres to all policies and regulations as set forth by school administration, Health Science teacher, and

healthcare agency.8. Shall, at the student’s expense, take required physical examinations or TB tests if required by the program and/or

the healthcare site.9. Shall not perform duties in which he/she has not received instruction.

10. Any student failing to comply with policies, rules and regulations is subject to dismissal from the program.11. Shall be responsible for transportation to and from the healthcare site.12. Shall not displace adult workers who can perform such work as assigned in the work-based experience.

Health Science Teacher13. Secures appropriate experiences for career shadowing based on the student’s career objective/pathway.14. Counsels the student about the shadowing experience, behavior, attitude, academics, etc.15. Reinforces career shadowing experience with related classroom instruction.

Healthcare Agency/Preceptor16. Recognizes that the student is participating in a Health Science Career Shadowing experience designed to prepare

for a career in a Health Science or related occupation.17. Provides supervision and instruction of the student in acquiring the competencies necessary for success in their

career objective during the career shadowing experience.18. Employs a non-discrimination policy with regard to race, color, handicap, sex, religion, national origin, creed, or

age.19. Adheres to wage and hour; child labor; and all other federal, state, and local laws pertaining to student

employment.

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Signatures are required for student to participate in Health Science Career Shadowing.

__________________________ Date

Parent/Legal Guardian Student Healthcare Preceptor(If student shadowing with

a preceptor)

Health Science Teacher School Administrator Healthcare Agency

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STUDENT CONFIDENTIALITY AGREEMENT

As a student, you may have access to what this agreement refers to as “confidential information.” The purpose of this agreement is to help you understand your duty regarding confidential information in the healthcare setting.

Confidential information includes patient’s personal and medical information, employee/volunteer/student information, financial information, other information relating to healthcare agency, and information proprietary to other companies or persons providing services to agency or patients/employees. You may learn of or have access to some or all of this confidential information through a computer system or through your rotational/observation activities.

Confidential information is valuable and sensitive and is protected by law and by strict agency policies. The intent of these laws and policies is to ensure that confidential information will remain confidential – that is, that will be used only as necessary to accomplish the organization’s mission. As a student, you are required to conduct yourself in strict conformance to applicable laws and agency policies governing confidential information. Your principal obligations in this area are explained below. You are required to read and to abide by these duties. The violation of any of these duties will subject you to discipline, which might include, but is not limited to, termination of rotation/observation experience and legal liability.

As a student, you understand that you will have access to confidential information that may include, but is not limited to, information relating to:

Patients (such as medical records, conversations, admittance information, patient financial information, etc.)

Employee/volunteers/students (such as salaries, employment records, disciplinary actions, etc.) Agency information (such as financial and statistical records, strategic plans, internal reports, memos,

contracts, peer review information communications, proprietary computer programs, source code, proprietary technology, etc.)

Third-party information (such as computer programs, client and vendor proprietary information, source code, proprietary technology, etc.)

Accordingly, as a condition of and in consideration of your access to confidential information, you promise that:

1. You will use confidential information only as needed to perform your legitimate duties as a student. This means that among other things, that:

a. You will only access confidential information for which you have a need to know.b. You will not in any way copy, release, sell, loan, review, alter, or destroy and confidential

information except as properly authorized within the scope of your professional activities affiliated with agency.

c. You will not misuse confidential information or carelessly care for confidential information.

2. You will safeguard and will not disclose any access code or any other authorization you have that allows you to access confidential information.

3. You accept responsibility for all activities undertaken using your access code and other authorization.

4. You will report activities by any individual or entity that you suspect may compromise the confidentiality of confidential information. Reports made in good faith about suspect activities will be held in confidence to the extent permitted by law, including the name of the individual reporting the activities.

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5. You understand that your obligations under this Agreement will continue after termination of your rotation/shadowing experience. You understand that your privileges hereunder are subject to periodic review, revision, and if appropriate, renewal.

6. You understand that you have no right or ownership interest in any confidential information referred to in this agreement. Agency may at any time revoke your access code, other authorization, or access to confidential information. At all times during your rotation/observation experience, you will safeguard and retain the confidentiality of all confidential information.

7. You will be responsible for your misuse or wrongful disclosure of confidential information and for your failure to safeguard your access code or other authorization access to confidential information. You understand that your failure to comply with this Agreement may also result in your loss of employment with agency.

_______________________________________________ ________________________Student Signature Date



SCHOOL-BASED ENTERPRISES

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DefinitionA school-based enterprise is a simulated or actual business usually conducted on the school site as component of a CTE course. Students create and operate an economically viable venture that replicates a specific business or industry and generates revenue for the CTSO or school. School-based enterprises are activities through which students produce or provide goods or services for sale or for use by people other than themselves. This experience may be supervised by any CTE certified teacher.

Purpose/ObjectiveThe purpose is to assist students in acquiring work experience related to their chosen career pathway. School-based enterprises are often provided in communities without a sufficient number of businesses or industry to provide student employment experiences.

PrerequisitesNo credit will be earned.

Related InstructionStudents must be currently enrolled in the sponsoring teacher’s related class while participating in the school-based enterprise.

Student QualificationsThe student must be:

Approved for participation by the related Career and Technical Education teacher In grades 9 –12.

Roles and Responsibilities Students comply with the rules and regulations of the school-based enterprise.

Parents/Guardians approve and encourage student participation in the school-based enterprise. They assume responsibility for the conduct of the student and agree to provide transportation to and from the School-Based Enterprise if applicable.

Career and Technical Education Teachers leads in developing an appropriate school-based enterprise. They provide supervision during the school-based enterprise and counsel the student regarding his/her job performance. They determine the student’s final grade and reinforce work-based learning experiences with related classroom instruction.

Appropriate PlacementSchool-based enterprise placement shall be based upon the student’s career objective.

Credits Earned

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No credit is earned except as an integrated component of a Career and Technical Education course.

Hour Requirements Hours are facilitated by the sponsoring Career and Technical Education teacher.

Supervision Requirements Supervision will be performed by the CTE teacher.

Job Placement Restrictions or Limitations N/A

Wages School-based enterprises are nonpaid work-based experiences.

Insurance Coverage All students should show proof of current health insurance coverage, if applicable. If the student must drive in conjunction with the school-based enterprise, he/she must have a valid driver license and provide proof of automobile liability coverage.

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INDUSTRY TOURS AND JOB FAIRS

Definition An industry tour/job fair is an excursion or planned work-based learning experience for a group of students allowing them to explore or observe occupations. This can be accomplished virtually, by visiting a place of business, or through the interaction with individuals with first-hand experience in a particular career cluster. This experience may be supervised by a Career and Technical Education (CTE) certified teacher.

Purpose/ObjectiveThe purpose of industry tours/job fairs is to provide students with an informative introduction to careers and career clusters.

Prerequisites & Related InstructionNone

Student Selection/QualificationsStudent selection for participation in industry tours/job fairs is to be determined by the Local Education Agency (LEA). Students in grades 7-12 can benefit from this experience.

Roles and ResponsibilitiesThe student is responsible for demonstrating a business-like attitude and appropriate conduct. Appropriate PlacementN/A

Credits EarnedCredit is not awarded for this work-based learning experience.

Hour Requirements N/A

Supervision/Coordination Requirements Adequate supervision as required by the (LEA) to participate in the experience.

Job Placement Restrictions or Limitations N/A

Required Documentation & Forms Each student should submit forms required for participation by the LEA

Wages Industry Tours/Job Fairs are nonpaid work-based experiences.

Insurance CoverageEach student participating in the experience should be covered by personal insurance or group coverage offered by the school or activity sponsor, if applicable.

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JOB SHADOWING

Definition Job Shadowing is a work-based learning experience that provides students an opportunity to explore various careers by observing workplace mentors in actual work situations

Purpose/ObjectiveThe purpose of Job Shadowing is to provide students with an introduction to specific careers and career clusters.

PrerequisitesNone

Related InstructionNone

Student Selection/QualificationsStudent selection for participation in Job Shadowing is to be determined by the Local Education Agency (LEA). Students in grades 7-12 can benefit from this work-based learning experience.

Roles and ResponsibilitiesThe student is responsible for demonstrating a business-like attitude and appropriate conduct.

Appropriate PlacementN/A

Credits Earned and Hour RequirementsCredit is not awarded for this work-based learning activity.

Supervision/Coordination Requirements Adequate supervision as required by the LEA.

Job Placement Restrictions or Limitations In Job Shadowing situations extreme care should be used when selecting the locations and occupations to be shadowed.

Required Documentation & Forms Each student should submit permission forms signed by the parent/guardian as required by the LEA to participate in the work-based learning experience. Additional requirements may be established by the school or LEA.

Wages N/A

Insurance CoverageEach student participating in Job Shadowing should be covered by personal insurance or through group coverage provided by the school or activity sponsor, if applicable.

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ALSDE-APPROVEDWORK-BASED LEARNING PILOT EXPERIENCE

Definition Work-based learning pilot experiences are created to address business and community needs within a specific geographical area. These experiences must be approved by the State Superintendent of Education after application to the State Director of Career and Technical Education (CTE). The work-based experience is supervised by a CTE teacher who holds a Class B certification or higher, has taken Functions of the Coordinator or Principles of Coordination Coursework and has completed two hours of child labor law training annually. A work-based learning pilot experience shall remain under pilot status for up to three years at which time it shall meet the requirements of an SDE approved Industry-Based Work Experience or be terminated.

Purpose/ObjectiveThe purpose of the work-based learning pilot experience is to provide specific training in high skill, high wage, and high demand occupations that address critical business and industry demand for labor within a specific geographic area.

Application ProcessA proposal shall be made to the State Director of Career and Technical Education detailing the need for the experience and stating why the employment needs cannot be met through existing work-based learning experiences. If the experience is deemed to meet a viable need it will be forwarded to the State Superintendent of Education for consideration and approval. The proposal shall include the following information:

The LEA(s) to be involved in the experience. A detailed description of the experience to include business and community need. The outlook for high paid, high skill, and high-demand careers after completion of the

experience. Current approved Alabama Course of Study: Career and Technical Education courses

and content standards that are applicable to the proposed experience. Impact on the community, student, and school. Appropriate CTSO affiliation Student credentialing opportunities

PrerequisitesTo be determined based upon proposal.

Related InstructionTo be determined based upon proposal.

Student Selection/QualificationsTo be determined based upon proposal.

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Roles and ResponsibilitiesTo be determined based upon proposal.

Appropriate PlacementTo be determined based upon proposal.

Credits EarnedTo be determined based upon proposal.

Hour Requirements To be determined based upon proposal.

Supervision/Coordination Requirements To be determined based upon proposal.

Job Placement Restrictions or Limitations To be determined based upon proposal.

Required Documentation & Forms To be determined based upon proposal.

Wages To be determined based upon proposal.

Insurance Coverage/Workers’ Compensation To be determined based upon proposal.

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ALSDE-APPROVEDINDUSTRY-BASED LEARNING EXPERIENCE

Definition Industry -based work experience programs are created as a result of completion of a Work-Based Learning Pilot experience. It addresses business and community needs within a specific geographical area. These experiences must be approved by the State Superintendent of Education after application to the State Director of Career and Technical Education (CTE). The industry based experience is supervised by a CTE teacher who holds a Class B certification or higher, has taken Functions of the Coordinator or Principles of Coordination Coursework and has completed two hours of child labor law training annually.

Purpose/ObjectiveThe purpose of the industry-based learning experience is to provide specific training in high skill, high wage, and high demand occupations that address critical business and industry demand for labor within a specific geographic area.

Application ProcessA proposal shall be made to the State Director of Career and Technical Education detailing the need for the experience and stating why the employment needs cannot be met through existing work-based learning experiences. It shall outline in detail the activities of the pilot program that has lead to the formal establishment of the industry-based learning experience. If the experience is deemed to meet a viable need it will be forwarded to the State Superintendent of Education for consideration and approval. The proposal shall include the following information:

The LEA(s) to be involved in the experience. A detailed description of the experience to include business and community need. The outlook for high paid, high skill, and high-demand careers after completion of the

experience. Current approved Alabama Course of Study: Career and Technical Education courses

and content standards that are applicable to the proposed experience. Impact on the community, student, and school. Appropriate CTSO affiliation Student credentialing opportunities

PrerequisitesTo be determined based upon proposal.

Related InstructionTo be determined based upon proposal.

Student Selection/QualificationsTo be determined based upon proposal.

Roles and Responsibilities

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To be determined based upon proposal.

Appropriate PlacementTo be determined based upon proposal.

Credits EarnedTo be determined based upon proposal.

Hour Requirements To be determined based upon proposal.

Supervision/Coordination Requirements To be determined based upon proposal.

Job Placement Restrictions or Limitations To be determined based upon proposal.

Required Documentation & Forms To be determined based upon proposal.

Wages To be determined based upon proposal.

Insurance Coverage/Workers’ Compensation To be determined based upon proposal.

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Resources/Contacts

Resources:

Alabama State Department of Educationwww.alsde.edu

Alabama Career and Technical Educationwww.alcareertech.org/

Alabama State Department of Laborwww.labor.alabama.gov

Contacts:

Registered Apprenticeships

Rowland (Ron) C. Dixon, Alabama State DirectorU.S. Department of LaborEmployment Training Administration Office of ApprenticeshipMedical Forum Building, Room 648950 22nd Street NorthBirmingham, Alabama 35203(205) [email protected]

Child Labor Contacts

Adam Strickland, Child Labor InspectorAlabama Department of LaborChild Labor Division100 North Union Street, Suite 620Montgomery, Alabama 36130(334) [email protected]

Brian Gates, Child Labor InspectorAlabama Department of LaborChild Labor Division100 North Union Street, Suite 620Montgomery, Alabama 36130(334) [email protected]

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mailto:[email protected]



http://www.labor.alabama.gov/

http://www.alcareertech.org/

http://www.alsde.edu/

AcknowledgementsThe Alabama State Department of Education would like to acknowledge the contributions of the following individuals who worked to develop this manual for work-based learning. Without their time, efforts, and contributions this manual would not have been possible.

Work-Based Learning Committee

Rochelle Seals, Education SpecialistProject ManagerAlabama State Department of Education

Joyce CoadyAutauga County Technology CenterAutauga County Schools

Debra PenhaleThompson High SchoolShelby County Schools

Kimberly DavisWalker High SchoolJasper City Schools

Mancel RegisterSchool of TechnologyShelby County Schools

Allen FranklinBibb County Career AcademyBibb County Schools

Aletha ReynoldsRobert E. Lee High SchoolMontgomery County Schools

Maisie HalesChambers County Career Technology CenterChambers County Schools

Billie June RialsGeneva County High School/Samson High SchoolGeneva County Schools

Tiffeny HowardFoley High SchoolBaldwin County Schools

William TroutmanCullman Area Career CenterCullman City Schools

Shannon PairFort Payne High SchoolFort Payne City Schools

Diane YoungBrewbaker Technology Magnet SchoolMontgomery County Schools

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Alabama State Department of EducationCareer and Technical Education Staff

Philip Cleveland, Director

Dawn Morrison, Education Administrator Jacob Davis, Education Administrator

Nan Burgess, Education Administrator Esther Hicks, Education Specialist

Craig Collins, Education Administrator Petro Johnson, Education Specialist

Tina DeBruyne, Education Administrator Christopher Kennedy, Education Administrator

Susan Harrison, Education Administrator Myron Laurent, Education Specialist

Margaret Smith, Education Administrator Mandy Nichols, Education Specialist

Mary Simon, Education Administrator Philip Paramore, Education Specialist

Collie Wells, Education Administrator Ben Scheierman, Education Specialist

Jennifer Adams, Education Specialist Rochelle Seals, Education Specialist

Judy Brown, Education Specialist Lisa Weeks, Education Specialist

Mylinda Brown, Education Specialist

Alabama State Department of EducationState Director’s Advisory Council

Greg AllenDothan City Board of Education

Tommy R. GlasscockChilton County Board of Education

David AsburyGadsden City Board of Education

Kay HarrisJefferson County Board of Education

Christie CaineSylacauga City Board of Education

Glenn MaloyHouston County Career Technical Center

SoJuan CrenshawAlabama Youth Services

Julie SimmonsPike County Schools/Troy City Schools

Harold Crouch Washington County Board of Education

Carl ThomasElmore County Board of Education

Terry Foshee Etowah County Board of Education

Camille WrightMadison City Board of Education

Ann GilmoreAlabama Association for Career and Technical Education

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Alabama State Department of EducationCareer and Technical Education Advisory Council

Bob Higgins, ChairBaldwin County Economic Development Alliance

Jacqueline AllenAlabama Industrial Development Training (AIDT)

Connie BainbridgeCentral Alabama Electric Cooperative

Grady L. BatchelorIndustrial Development Authority of Winston County

Marissa BatesHorse Shoe Bend High SchoolFamily, Career and Community Leaders of America (FCCLA)Felicia Williams, Adviser

Ronald BolesGeneral and Automotive Machine Shop, Inc.

Donna BowdenAlabama Department of Rehabilitation Services

Powell BrewtonPowell Brewton Consultants

Linda CaterAlabama Department of Postsecondary Education

Dr. LaRonda ConleyScience and Technology Division Advanced Technology Directorate Missile Defense Agency

Sam CovertAlabama Power Company

Sam DiChiaraCentral High School, Future Business Leaders of America (FBLA)Terry Daniels, Adviser

Ron DixonU.S. Department of Labor

Gene DudleyDepartment of Postsecondary Education

Bobby Joe EmmonsBaldwin County High SchoolTechnology Student Association (TSA)Jeff Boone, Advisor

Vickie FussellHope Place Family Resource

Lacy GibsonAlabama Hospital Association

Ann GilmoreAlabama Association for Career and Technical Education

Steve GoldsbyIntegrated Computer Solutions, Inc.

Dr. Ken HollingsworthAlabama Department of Economic and Community Affairs

Angela HollowellRussell County High School, Health Occupation Student Organization(HOSA)Tywanna Robinson, Adviser

Hank Jones(Retired) Superintendent, Troy City Schools

Sue JonesAlabama Department of Public Health

Julie KornegayFederal Reserve Bank of Atlanta

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Alabama State Department of Education Career and Technical Education Advisory Council

(continued)

Dr. Neil LambHudson Alpha Institute of Biotechnology

Dave LatonAlabama Department of Postsecondary Education

Marcus LundyThe Chamber for Regional Prosperity

J.T. McCartneyMcCartney Construction Company, Inc.

Natasha MilesBrewbaker Technical Magnet High School, Alabama SkillsUSAWalt Thomas, Adviser

Mary MullenAnniston Army Depot Career Academy

Leanna ParkerDemopolis High School, DECALucinda Mason, Advisor

Kathryn RayMontevallo High School, FFA-Agriscience EducationMatt Barton, Adviser

Anje RooneyBirmingham Business Alliance

Debbie StoneMando America Corporation

Carl ThomasElmore County Technical Center

Phillip TruedAnniston Army Depot

Victor VernonBusiness Council of Alabama

Chester VrocherAlabama Technology Network

The committee would also like to acknowledge contributions and information from the following:

Georgia State Department of Education Career and Technical Education

Iowa State Department of Education Career and Technical Education

Kentucky State Department of Education Career and Technical Education

Marketing and Business Administration Research Center

Minnesota State Department of Education Career and Technical Education,

National Commission for Cooperative Education

Tennessee State Department of Education Career and Technical Education

U.S. Department of Labor

Virginia State Department of Education Career and Technical Education

West Virginia State Department of Education Career and Technical Education

Wisconsin State Department of Education Career and Technical Education

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BibliographySwail, Watson S. and Kampits, Eva. (2004). Work-Based Learning and Higher Education: A

Research Prospective. Washington, DC: Educational Policy Institute.

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Revision Committee MembersNovember 20, 2014

Mike Rutledge, Cooperative EducationAlabama Department of Education

Steven W. BoydBessemer High SchoolBessemer City Schools

Christie CaineSylacauga High SchoolSylacauga City Board of Education

Joyce FolkHuntsville Center of Technology Huntsville City Schools

Nancy Prine Career Tech SupervisorMobile County Public Schools

Linn PritchettBrookwood High SchoolTuscaloosa County Schools

Billie June RialsGeneva County High School/Samson High SchoolGeneva County Schools

Walt SimmonsEtowah County Career Technical CenterEtowah County Schools

William TroutmanCullman Area Career CenterCullman City Schools

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