COE Co-op Student Work Report Form - Cooperative Education and Internship Program (CEIP)College of Engineering

Student Work Session Report & Survey Form

Please complete this form. Thank you!

Fill out the information requested below and, when done, click the "Submit Form" button. Use the tab key to move between fields. Note that the Enter Key will submit the form before it is completed.

Items marked * are required fields!

Student Information
Last Name	*
First/Middle Name	* (First Middle)
Student Identification Number	* (NOT your SSN)
School Email	@umassd.edu *
Major
Work Information
Employer (Company Name)
Street Address
City
State
Zip Code
Supervisor's Last Name	*
Supervisor's First/Middle Name	* (First Middle)
Supervisor's Email Address	*
Department
Semester & Year Worked:
Hours per week
Salary per hour
What (if any) benefits are provided?
Future Plans
Do you intend to return to your present co-op/ internship assignment?	Yes No Undecided Graduating
If yes, when?	(MM/YYYY)
If you are graduating, have you been offered employment by this company?	Yes No
If yes, how did you respond to the offer?	I Accepted I Declined I am still deciding
Semester Report
For how many terms have you been working for this employer? (Please select a term to fill/review additional questionnaires.)	One term Two terms Three terms Four or more terms

Signature	(Please Initial Here) *
Security Image:	*

Select a work term
Answer the following questions regarding your experience this term.
	Yes Mostly Somewhat Not really No
	Yes Mostly Somewhat Not really No
	Yes/Always Frequently As needed Seldom No/Never
	Yes Mostly Somewhat Not really No
	Yes Mostly Somewhat Not really No
	Yes/Always Frequently As needed Seldom No/Never
	Yes/Always Frequently As needed Seldom No/Never
	A lot Really well A little Not at all
	Yes No
	Yes No
	Yes No

	Excellent Very Good Average Satisfactory Poor

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Student Work Session Report & Survey Form

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