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Work-Based Learning Program
Work-Based Learning Manual - Forms

"There are a lot of ways people learn. You can learn in the classroom, but the best learning sometimes takes place actually on the job. First of all, it's a clearly applied skill. Second of all, it's a very specific skill and one that really matters. We're finding that many of our children learn better in an actual work setting, particularly when it is combined with an academic experience."
– Michael O. Leavitt, Former Governor of the State of Utah

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General Required Forms

  • Application for Internship - Word
  • Confidentiality for Students - Word
  • Disclosures for Internship 
    >Disclosure #1 - Word
    >Disclosure #2 - Word
  • Emergency Notification - Word
  • Harassment Safety Training - Word
  • Hazardous Occupations Verification - Word
  • Media Release - Word
  • Skills Grids
    Use to set intern/mentor goals and identify skills in resume.
    >Skills Grid - Word
    >Skills Grid Sample, Accounting - Word
    >Skills Grid Sample, EMT - Word
    >Skills Grid Sample, Law Office - Word
    >Skills Grid Sample, TV/Radio Sports - Word
  • Student Intern Commitment - Word
  • Student Intern Evaluations
    >Student Intern Evaluation - Word
    >Student Intern Evaluation Quarter #1 - Word
    >Student Intern Evaluation Quarter #2 - Word
    >Student Intern Self-Evaluation - Word
  • Time Sheets
    >Time Sheet #1 - Word
    >Time Sheet #2 - Word
    >Time Sheet #3 - Word
    >Time Sheet #4 - Word
    >Time Sheet #5 - Word
  • Training Agreements
    >Training Agreement #1 - Word
    >Training Agreement #2 - Word
    >Training Agreement #3 - Word
  • Transportation Form - Word
  • Workers Compensation Injury Report - Word


Medical Required Forms

  • Confidentiality for Medical Interns - Word
  • HIPAA Agreement - Word
  • IHC Access and Confidentiality Agreement - Word
  • Medical Confidentiality Statement - Word
  • Medical Internship Disclosure - Word
  • Medical Internship Immunizations Record - Word
  • Ride-A-Long Permission for EMTs - Word


Other Forms

  • Injury Witness Statement - Word
  • Internship Accountability - Word
  • Intern Checklist - Word
  • Job Shadow Feedback - Word
  • Mentor or Business Partner Information - Word
  • Mentor Orientation Checklist - Word
  • Parental Consent for Disclosure - Word
  • Scheduler for WBL Internship - Word
  • Student Internship Journal - Word
  • Student Schedule Outline - Word
 

Updated August 14, 2014  


 

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Download Program Flyer - PDF

CTE...Giving Students the Edge

FOR MORE INFORMATION:
sherry [dot] marchant [at] schools [dot] utah [dot] gov (Sherry Marchant), Specialist
Work-Based Learning
Phone: 801>538-7594
Fax: 801>538-7868

maggie [dot] bradshaw [at] schools [dot] utah [dot] gov (Maggie Bradshaw) , Support Staff
Work-Based Learning
Phone: 801>538-7941




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