CWD - WBL - Work Based Learning Employer Pre-Assessment Form

Employer Pre-Assessment

Please complete this pre-assessment to give our Industry Engagement team more information regarding your needs so we may best serve you.
Business Information
Business Name*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*
Please enter a valid phone number.
Email*
example@example.com
Website
Number of Current Employees*
Point of Contact

This point of contact will be person who will “champion” the work-based learning at the business and be the liaison with CSM’s Industry Engagement team.
Title*
Name of Intern's Supervisor*

First NameLast Name
Where did you learn about Work-Based Learning?*

CSM WebsiteCSM AlumniCSM FacultyBusiness OwnerSocial MediaCommunity OrganizationCSM Staff MemberOther
Is this a registered apprenticeship opportunity?
How many paid internship positions are to be filled?*
Quantity for singular job description.
Position Information
Does this job/positions require U.S. work authorization?
Require Work Authorization Answer*
Eligibility for international students (non-US citizens or permanent residents):

Would you sponsor a work visa for the right candidate?
Sponsor Work Visa Answer*
Are you willing to hire candidates that are temporarily authorized to work for a defined period in their field of study? (i.e., for a job/internships under OPT/CPT)
Temporarily Authorized to Work Answer*
Position title*
Number of weekly hours (no less than 15 hours per week)*
*WBL opportunity must be a minimum of 15 hours per week.
Weekly work schedule (day(s) of week and hours)*
Hourly wage*
When would you like the internship to begin?*
Duration of work-based learning experience*
Will the intern fill a current job opening or act as additional staff?
Position Description - As a part of the position description, please provide a list of skills that the student will learn during the work-based learning experience.

If you need assistance creating a position description, please see the sample position description template at www.csmd.edu/WBL.
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Additional job qualifications desired. Please be sure to include any requirements such as background and/or drug screen, security clearance, driver’s license/driving record.
Please indicate any physical requirements (able to lift x number of pounds, works with hazardous materials, work place hazards, etc.)
Additional Information
Do you have additional training/professional development programs in place that the student can participate in?
FOR OFFICE USE: Industry Code(s)
FOR OFFICE USE: Student placed?
FOR OFFICE USE: Start and End Date of Placement
FOR OFFICE USE: Date Contract Sent to Employer
FOR OFFICE USE: Notes
Should be Empty:

Employer Pre-Assessment

Business Information

Point of Contact

Position Information

Additional Information