WORKSITE QUALIFICATION FORM

     
    COMPANY NAME:
    EMPLOYER’S IRS IDENTIFICATION #
    ADDRESS
    CITY/STATE/ZIP
    HOURS OF OPERATION: WEB SITE:
    LEAD CONTACT
    PHONE: FAX:
      
    POTENTIAL DEPARTMENT FOR HOSTING STUDENTS
    1) 5)
    2)6)
    3) 7)
    4) 8)
    AGE REQUIREMENTS OF STUDENTS
    # OF STUDENTS – HOSTING CAPACITY:
       
    QUALIFICATIONS – GENERAL EVIDENCE
    Is there a Current Minor Worker Permit Posted? If not, is the worksite willing to apply for one 
      
    Will students be placed in occupations that are permitted by Federal and State Child Labor Laws? 
      
    Does the Worksite have an Equal Employment Opportunity Policy in place & visible to all employees? 
      
    Are there any Union issues with placing youth at this Worksite? 
      
    Will students be placed in meaningful Work-Based Learning Activities that fall under a High School Career Pathway? 
    QUALIFICATIONS–GENERAL CONT) EVIDENCE
    Will students contribute to the overall functioning of the work site?  
      
    Will worksite Mentors be available to assist in the development of student’ ;s learning objectives and communicate regularly with the Work-Based Learning Coordinator? 
      
    Will worksite Mentors be willing to sign all Work-Based Learning Forms and adhere to all WBL/WSL Program Policies? 
      
    Will students be employed as additional resources so that they do not displace existing employees? 
      
    Will the worksite provide the necessary tools, equipment and supplies students need in order to perform work duties? What will be the responsibility of the student to bring to the job? 
      
    Will the worksite provide students with exposure to various occupational areas?  
      
    If the worksite is a Private, For-Profit Organization, will there be opportunities for students to be placed in permanent positions? 
      
    Is the worksite easily accessible for students who are driving or taking the bus? 
      
    Does the worksite promote an environment where youth are valued and are viewed as important members of a team? 
      
      
      
    QUALIFICATONS-STUDENT SAFETY EVIDENCE
      
    Does the worksite have a formal training process in place to train students on:

    1) Safety Hazards (ex, heavy lifting, chemicals, equipment operation, etc)

    2) Work Environment Issues (ex. Sexual harassment, angry customers, etc.)

    3) Emergency Situations (ex. 1 st Aid, Fire, etc.)

    		 
      
    Does the worksite have a system in place for inspecting the workplace and correcting safety hazards promptly? 
      
    Does the worksite have a process for assessing employees in order to determine whether or not a student can safely perform a particular duty or operate a particular piece of equipment? 
      
    Does the Worksite have an Injury & Illness Prevention Program? 
      
    Are all containers of toxic materials labeled with the chemical name, hazard warnings, and name and address of the manufacturer?  
       
    Are Material Safety Data Sheets (MSDS’s) for all chemicals in the worksite easily accessible to students? 
      
    Does the worksite provide all necessary safety and protective equipment to students? If not, what will be the responsibility of the student to bring to the job? 
      
      
      
      
    HOSTING WORKSITE HISTORY EVIDENCE
       
    Has this worksite ever been used as a Work-Based Learning site? 
      
    Has this Worksite ever hosted youth from WBL programs? For how many years?  
      
    Have there ever been any issues employer or student-related with this worksite?   

     

     

     

    THIS WORKSITE REVIEWED BY:

     

     

    SIGNATURE TITLE & ORGANIZATION

     

     

     

    THIS WORKSITE IS/IS NOT CERTIFIED TO HOST WBL ACTIVITIES

     

     

     

     

     

     

     

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