Work Experience Evaluation

Cooperative Education
Work Experience Evaluation

Student and Supervisor MUST complete this form TOGETHER
Student Full Name *
Palomar ID #*
Student Email*
Email used for all Work Experience Correspondence
Company Name *
Where do you work?
Supervisor Name*
Supervisor Phone Number*
Please enter a valid phone number.
Supervisor's Email*
example@example.com
Class #
Units
Semester/Year
Student: Please reenter your learning objectives below
Objective 1*
Objective 2*
Objective 3*
END of Class:

Student and Supervisor must complete this form together.
Student, enter total hours worked for the semester (from timesheet)*
Minimum of 162 hours are required to pass the class.
Student and Supervisor must each rate the student performance

Rating Scale:

4= Outstanding 3= Very Good 2 = Satisfactory 1 = Unsatisfactory
SUPERVISOR, please rate the student performance of the 3 learning objectives using the rating scale below.

Rating Scale: 4= Outstanding 3= Very Good 2 = Satisfactory 1 = Unsatisfactory
Objective 1*
Rating Scale: 4= Outstanding 3= Very Good 2 = Satisfactory 1 = Unsatisfactory
Objective 2*
Rating Scale: 4= Outstanding 3= Very Good 2 = Satisfactory 1 = Unsatisfactory
Objective 3*
Rating Scale: 4= Outstanding 3= Very Good 2 = Satisfactory 1 = Unsatisfactory
Supervisor End of Semester Comments:*
SUPERVISOR: I confirm the student has completed the total hours indicated above within the dates of course.

You can type your signature below. If you type your signature, you are agreeing that this form of signature is the equivalent of your physical signature.
Supervisor Name and Title *
Supervisor Signature*

Clear
Date*

MonthDayYear
Date
STUDENT, please rate your performance of the 3 learning objectives using the rating scale below.

Rating Scale: 4= Outstanding 3= Very Good 2 = Satisfactory 1 = Unsatisfactory
Objective 1*
Rating Scale: 4= Outstanding 3= Very Good 2 = Satisfactory 1 = Unsatisfactory
Objective 2*
Rating Scale: 4= Outstanding 3= Very Good 2 = Satisfactory 1 = Unsatisfactory
Objective 3*
Rating Scale: 4= Outstanding 3= Very Good 2 = Satisfactory 1 = Unsatisfactory
Student Full Name*
Student Signature*

Clear
Date*

MonthDayYear
Date
Should be Empty:

Cooperative Education

Work Experience Evaluation

END of Class: