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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
   

   
Signature      (Please Initial Here)   *    
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