"Internship Site Self Assessment and Student Acknowledgement of Risks - California State University"

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Internship Site Self-Assessment and Student Acknowledgement of Risks
This form is to be completed as soon as possible once the student has selected an internship assignment. This form is to be
completed by the Internship Site Representative and signed by both the Intern and the Internship site representative. The
University department’s Internship Coordinator will process, follow–up and maintain this document in the student’s file
Internship Site: _________________________________________ Telephone No: _______________________
Address: ______________________________________________ Email Address: _______________________
Internship Contact Name: _____________________________ Title: __________________________________
Internship Contact Signature:
_____
The following check box items are an indication of the safety and security at the Internship Site. N/A means
Not Applicable. If any item is checked NO, please explain on a separate page.
Is the site environment considered an “office exposure” only site?
Yes
No
N/A
Are emergency plans current?
Yes
No
N/A
Are hazardous materials or hazardous chemical controlled?
Yes
No
N/A
Are all manufacturing tools and equipment guarded?
Yes
No
N/A
Are interns provided with safety training prior to starting work?
Yes
No
N/A
Will intern wear personal protective equipment, if necessary?
Yes
No
N/A
Are working conditions and general environment safe?
Yes
No
N/A
Is there adequate employee parking on site?
Yes
No
N/A
Are parking areas well lit as necessary?
Yes
No
N/A
Is site accessible by public transportation?
Yes
No
N/A
Will interns be restricted from interacting with potentially violent clients?
Yes
No
N/A
Is management and supervisory oversight adequate?
Yes
No
N/A
Is the site located in a crime-free area?
Yes
No
N/A
Interns will not be required to drive as part of their responsibilities?
Yes
No
N/A
Interns will not be required to perform heavy manual labor?
Yes
No
N/A
Is the above site location the only place the intern will work?
Yes
No
N/A
I have evaluated and understand potential health and safety risks associated with this Internship Site. I have
undertaken additional research and/or visited the site in response to any no answers from the Internship Site.
I am able to articulate those risks to student who may choose to intern at this site.
Internship Coordinator’s Name: ________________________________________________________________
I have read and understand the potential health and safety risks associated with this Internship Site. I have
discussed these risks with the department’s Faculty Advisor or Internship Coordinator and accept this
internship as presented.
Student Name: ____________________________________________ Student ID No: ____________________
Address: _________________________________________________ Telephone No: ____________________
Internship Site Self-Assessment and Student Acknowledgement of Risks
This form is to be completed as soon as possible once the student has selected an internship assignment. This form is to be
completed by the Internship Site Representative and signed by both the Intern and the Internship site representative. The
University department’s Internship Coordinator will process, follow–up and maintain this document in the student’s file
Internship Site: _________________________________________ Telephone No: _______________________
Address: ______________________________________________ Email Address: _______________________
Internship Contact Name: _____________________________ Title: __________________________________
Internship Contact Signature:
_____
The following check box items are an indication of the safety and security at the Internship Site. N/A means
Not Applicable. If any item is checked NO, please explain on a separate page.
Is the site environment considered an “office exposure” only site?
Yes
No
N/A
Are emergency plans current?
Yes
No
N/A
Are hazardous materials or hazardous chemical controlled?
Yes
No
N/A
Are all manufacturing tools and equipment guarded?
Yes
No
N/A
Are interns provided with safety training prior to starting work?
Yes
No
N/A
Will intern wear personal protective equipment, if necessary?
Yes
No
N/A
Are working conditions and general environment safe?
Yes
No
N/A
Is there adequate employee parking on site?
Yes
No
N/A
Are parking areas well lit as necessary?
Yes
No
N/A
Is site accessible by public transportation?
Yes
No
N/A
Will interns be restricted from interacting with potentially violent clients?
Yes
No
N/A
Is management and supervisory oversight adequate?
Yes
No
N/A
Is the site located in a crime-free area?
Yes
No
N/A
Interns will not be required to drive as part of their responsibilities?
Yes
No
N/A
Interns will not be required to perform heavy manual labor?
Yes
No
N/A
Is the above site location the only place the intern will work?
Yes
No
N/A
I have evaluated and understand potential health and safety risks associated with this Internship Site. I have
undertaken additional research and/or visited the site in response to any no answers from the Internship Site.
I am able to articulate those risks to student who may choose to intern at this site.
Internship Coordinator’s Name: ________________________________________________________________
I have read and understand the potential health and safety risks associated with this Internship Site. I have
discussed these risks with the department’s Faculty Advisor or Internship Coordinator and accept this
internship as presented.
Student Name: ____________________________________________ Student ID No: ____________________
Address: _________________________________________________ Telephone No: ____________________