Cooperative Education and Internship Program (CEIP)College of Engineering 

Student Work Session Report & Survey Form


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Student Information
Last Name   *
First/Middle Name   *   (First Middle)
Student Identification Number   *   (NOT your SSN)
School Email  @umassd.edu  *
Major
Work Information
Street Address
City
State
Zip Code
Supervisor's Last Name   *
Supervisor's First/Middle Name   *   (First Middle)
  *
Future Plans
Yes
No
Undecided
Graduating
  (MM/YYYY)
Yes
No
I Accepted
I Declined
I am still deciding
Semester Report
One term
Two terms
Three terms
Four or more terms

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
Signature   (Please Initial Here)   *
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