Internship Site Summary 2024

Internship Site Summary

Larimer County Economic and Workforce Development Department
Date Submitted*

MonthDayYear
Business Information
Business Name*
Federal Employer ID Number (FEIN)*
Business Location*

Street Address

Street Address Line 2

CityState

Zip Code
Primary Supervisor's Name*

First NameLast Name
Primary Supervisor's Title / Department*
Primary Supervisor's Phone Number*

Area CodePhone Number
Primary Supervisor's E-Mail*
Back-up Supervisor's Name

First NameLast Name
Back-up Supervisor's Title / Department
Back-up Supervisor's Phone Number

Area CodePhone Number
Back-up Supervisor's E-mail
Company Website Address*
Enter URL or N/A if not applicable
How many employees does your business have?*
LCEWD Contact:
LCEWD Contact*
Prepared by:*
Internship Position Information
Internship Position Title*
Give a general description of the tasks involved in this position (if possible, attach a job description with this site summary).*
Will this position be:*

Full RemoteHybridFull Onsite
Are any specific skills, training, or experience required prior to placement in internship?*

YesNo
What skills, training or experience are required, please explain:*
What skills will the candidate gain during this internship?*
Additional comments specific to your worksite (ie. age, bilingual skills, dress code, specific clothing / equipment required).
Select the option(s) that best describes your working environment.*

Teamwork concept (lots of interactions with co-workers)Very busy (hectic - must meet deadlines)Busy (steady workload)Independant (work at your own pace, minimal contact with people)Intense (high volume traffic)Quiet (low volume traffic)
Approximately how many hours per week are needed to complete tasks?*
Please state the preferred work days and hours for this internship.*
How many interns can you host in this role?

1234+
If yes please explain*
Does the business require any of the following for ALL employees?*

Criminal background checkDrug screeningFingerprintingImmunizationsPhysicalsNo pre-employment requirementsOther
Would you consider an applicant with a criminal background?

YesPossibly, depending on the chargesNoYes, with the following exceptions
Please list exceptions:
How much noise is typical for the work environment for this internship?*

Very quiet (forest trail, isolation booth for hearing test)Quiet (library, private office)Moderate noise (business office with typewriters and printers, working outdoors)Loud noise (manufacturing, large earth moving equipment, mowers, weed eaters)Very loud noise (jackhammer work, front row at a rock concert)
Physical Requirements

What are the physical requirements for your site/position?*

	Never	Occasionally (up to 2 hrs per day)	Frequently (2-5 hrs per day)	Continuously (5 or more hrs with breaks)
Lift or Exert up to 10 lbs of force
Lift or Exert up to 20 lbs of force
Lift or Exert up to 50 lbs of force
Lift or Exert up to 100 lbs of force
Lift or Exert over 100 lbs of force
Climb ladders or other surfaces

If lifting 50 lbs. or more, will lift assist equipment or team lifting be required?*

YesNoN/A
Describe lifting and/or exertion conditions*
Safety Requirements

Check the extent of physical capacity requirements listed below:*

	Never	Occasionally (up to 2 hrs per day)	Frequently (2-5 hrs per day)	Continuously (5 or more hours with scheduled breaks)
Machinery with moving parts
Dust, fumes, gases, and airborne particles
Risk of electrical shock
Toxic or caustic chemicals
Work with explosives
Risk of radiation
Exposure to blood/bodily fluids

Is Personal Protective Equipment (PPE) used?*

YesNo
If yes, what protective equipment is used?*
Please describe the PPE used and situations it may be required for
Will driving any motorized vehicles be required for this internship?*

YesNo
Will driving any non-motorized vehicles be required in this internship? (i.e., tow motor, golf cart, lawn mower, etc.)*

YesNo
Is safety training provided?*

YesNo
If yes, what safety training is provided?*
Additional information you feel may not have been addressed above?
Interns may not operate a motor vehicle during work hours. This includes the intern’s personal vehicle. Please explain your situation:
For Larimer County Risk Assessment use only
Job Analysis Classification

SedentaryLightMediumHeavyVery Heavy*Not Yet ApprovedApproved
Lift test required for this position based on job demands?

YesNo
Comments
Risk Approval Signature

Clear
Job Order #:
Employer ID:
Larimer County Safer at Home Business/Facility Checklist

(updated 2/8/2021 -- subject to change per State orders)
Questions? Text 970-999-1770 or submit this form to send us an email.
Is there a possibility that an intern may work onsite at any point during their internship?*

YesNoUnsure
Business Name*
Signage*

Using templates provided by the Larimer County Health Department at each public entrance of the facility or location to inform all employees and customers;If not using existing templates, signage posted at each public entrance of the facility or location to inform all employees and customers must include:
Signage Requirements (check all that apply)

To avoid entering the facility or location if they have a cough or fever.Face coverings must be worn by all employees and customers.Social/Physical distancing requirements of maintaining a minimum six-foot distance between employees and customers.If relevant to your business type (e.g. personal services), that only 10 or fewer people are allowed in the facility at any given time, unless a variance request is submitted to the health department.
Measures to Protect Employee Health (check all that apply to the facility):

Everyone who can carry out their work duties from home has been directed to do so.At least 50% of the workforce is working remotely, or shifts have been staggered so no more than 50% of the typical workforce is on-site at any one time.All employees have been told not to come to work if sick (including any of the following- headache, sore throat, fever, dry cough, recent inability to taste and smell, shortness of breath, ear aches, body aches, diarrhea, fatigue, vomiting and abdominal pain).Symptom checks are being conducted before employees may enter the workspace.All desks, individual work stations or work areas are separated by at least six feet.Break rooms, bathrooms, and other common areas are being disinfected frequently, on the following schedule; (describe in the text field)Disinfectant and related supplies are available to all employees at either their workstations or the following location(s): (describe in the text field)Hand sanitizer effective against COVID-19 is available to all employees at either their workstations or the following location(s): (describe in the text field)Copies of this Protocol have been distributed to all employees.Optional—Describe other measures:
Break rooms, bathrooms, and other common areas are being disinfected frequently, on the following schedule:
Disinfectant and related supplies are available to all employees at either their workstations or the following location(s):
Hand sanitizer effective against COVID-19 is available to all employees at either their workstations or the following location(s):
Optional—Describe other measures:
Measures To Promote Physical Distancing (check all that apply to the facility):

Limit the number of customers and employees in facilities/business areas to 50% capacity, max 175 if the space allows for 6 feet of distancing at all times.If possible, an employee will monitor the door to ensure that the maximum number of customers in the facility set forth above is not exceeded.Placing tape or other markings at least six feet apart in customer line areas inside the store and on sidewalks to public entrances with signs directing customers to use the markings to maintain distance.Optional—Describe other measures used to reduce the number of employees and customers/clients to 50% capacity, max 175:
Describe other measures used to reduce the number of employees and customers/clients to 50% capacity, max 175:
Measures To Prevent Unnecessary Contact (check all that apply to the facility):

Preventing people from self-serving any items that are food-related.Lids for cups and food-bar type items are provided by staff; not to customers to grab.Bulk-item food bins are not available for customer self-service use.Providing for contactless payment systems or, if not feasible, sanitizing payment systems regularly.Providing curb-side drop-off/pick-up of products.Optional - Describe other measures (e.g. providing senior-only hours):
Describe other measures (e.g. providing senior-only hours):
Measures To Increase Sanitization (check all that apply to the facility):

Disinfecting wipes that are effective against COVID-19 are available near shopping carts and shopping baskets.Employee(s) assigned to disinfect carts and baskets regularly.Hand sanitizer, soap and water, or effective disinfectant is available to the public at or near the entrance of the facility, at checkout counters, and anywhere else inside the store or immediately outside where people have direct interactions.Disinfecting all payment portals, pens, and styluses after each use.Disinfecting all high-contact surfaces frequently.Optional—Describe other measures:
Describe other measures:
Measures To Reduce Exposures in Employee Transportation

Employee(s) are screened for COVID-19 symptoms each day and excluded from operations if symptomatic.Hand sanitizer is used by each employee when entering the vehicle and periodically during the shift.The number of passengers has been reduced by 50% of the vehicle occupancy and passengers sit in locations to maximize the distance between one another.Employees will wear a non-medical, cloth face covering when in a vehicle containing more than 1 person.Windows will remain open and ventilation is increased.Disinfecting all high-contact surfaces of the vehicle will be done at the end of each day.
* Any additional measures not included here should be listed on separate pages, which the business should upload to this form.
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You may contact the following employee with any questions or comments about this protocol:
Name*

First NameLast Name
Phone Number*

Area CodePhone Number
Email*
example@example.com
Questions? Text 970-999-1770 or submit this form to send us an email.
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Internship Site Summary

Business Information

LCEWD Contact:

Internship Position Information

Physical Requirements

Safety Requirements

Larimer County Safer at Home Business/Facility Checklist