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op Student Work Report Form

Cooperative Education and Internship Program (CEIP)   College of Engineering 

Student Work Session Report & Survey Form

Please complete this form. Thank you!

Fill out the information requested below and, when done, click the "Submit Form" button. Use the tab key to move between fields. Note that the Enter Key will submit the form before it is completed.

Items marked * are required fields!

Student Information
Last Name   *
First/Middle Name   *   (First Middle)
Student Identification Number   *   (NOT your SSN)
School Email  @umassd.edu  *
Major
Work Information

Street Address
City
State
Zip Code
Supervisor's Last Name   *
Supervisor's First/Middle Name   *   (First Middle)
  *





Future Plans
Yes
No
Undecided
Graduating

  (MM/YYYY)
Yes
No

I Accepted
I Declined
I am still deciding

Semester Report
One term
Two terms
Three terms
Four or more terms

Select a work term
Answer the following questions regarding your experience this term.
Yes Mostly Somewhat Not really No

Yes Mostly Somewhat Not really No

Yes/Always Frequently As needed Seldom No/Never

Yes Mostly Somewhat Not really No

Yes Mostly Somewhat Not really No

Yes/Always Frequently As needed Seldom No/Never

Yes/Always Frequently As needed Seldom No/Never

A lot Really well A little Not at all

Yes No

Yes No

Yes No


Excellent
Very Good
Average
Satisfactory
Poor



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