Cooperating Organization:____________________________________ Work Supervisor:__________________________

Organization Street Address:_______________________________________   Title:______________________________

City:______________________    State:_______   Zip:_________    Telephone Number:___________________________

Student:______________________________________________

Period of Work    From:_________________       To:_________________________

This report has been discussed with the student: ¨ Yes ¨ No

Please ignore any questions you think are inappropriate. Information as revealed below will assist the College of Applied Sciences and Arts in its counseling of the student.

1.   Please indicate the responsibilities and duties assigned to the Student-Employee, and comment on how well they were performed. Use the back of this form if needed.
 

Duties Assigned	How Well Performed
1.
2
3.
4.
5.

2.   The immediate supervisor will please evaluate the student objectively, comparing him with other students of comparable academic level, with other personnel assigned the same or similarly classified jobs, or with individual standards.
 

Item	Needs Attention	Does Well	Outstanding
Uses equipment/tools skillfully	¨	¨	¨
Job knowledge	¨	¨	¨
Follows instructions	¨	¨	¨
Accuracy, effectiveness, completeness	¨	¨	¨
Gets work done on time	¨	¨	¨
Quantity of work	¨	¨	¨
Interest in job	¨	¨	¨
Relations with supervisors	¨	¨	¨
Relations with public	¨	¨	¨
Cooperates with fellow employees	¨	¨	¨
Initiative and self-reliance	¨	¨	¨
Suitable appearance	¨	¨	¨
Attendance and punctuality	¨	¨	¨
Ability to learn	¨	¨	¨
Judgment	¨	¨	¨