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SL Self Assessment
Name of Partnership
*
Main Contact First Name
Main Contact Last Name
Main Contact Job Title
Main Contact Email Address
Main Contact Phone
Main Contact Phone, part 1
-
Main Contact Phone, part 2
-
Main Contact Phone, part 3
ext.
Main Contact Phone, part 4
Do you want to show Main Contact information to students?
Yes
No
Are you the main contact for this site?
Yes
No
Your First Name
*
Your Last Name
*
Your Email Address
Your Phone
Your Phone, part 1
-
Your Phone, part 2
-
Your Phone, part 3
ext.
Your Phone, part 4
Street Address
City
State
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Marshall Islands
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Marianas Islands
Ohio
Oklahoma
Oregon
Palau
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virgin Islands
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Zip Code
General Email Address
General Phone Number
General Phone Number, part 1
-
General Phone Number, part 2
-
General Phone Number, part 3
ext.
General Phone Number, part 4
Website
Social media site
What is a general description of your organization?
What will students be doing at your organization?
Please list an ongoing needs or projects with which students can assist agency staff.
Which Organization type best describes your site?
*
- Select -
Administrative Entity
Agriculture or Manufacturing
Arts, Entertainment or Recreation
Charity Organization/Foundation
Education - Administration/District
Education - Adult School
Education - Alternative School
Education - College or University
Education - Early Childhood
Education - Elementary School
Education - High School
Education - Middle School
Education - Multi-level
Education - Technical or Vocational
Educational Services, Training or Consulting
Environmental or Wildlife Organization
Financial or Insurance
Grassroots Organization
Healthcare Facility or Network
Historical Society/Museum or Library
Hospitality
Human, Social, or Employment Services
Judicial or Legal Facility/Organization
Military
Place of Worship/Meeting House
Political Organization
Public Utilities
Real Estate and Development
Research Institute
Residential or Home Care Facility
Retail Trade or Service Sector
Science, Technology or Engineering
Storage, Trade or Transportation
Please list any important information about your hours of operation
Include days and times that students can be on-site.
What are the minimum number of hours you require of a student serving at your site?
hours
What is the maximum number of students your site can accept?
students
Do you prefer students speak a language other than English?
American Sign Language
Arabic
Armenian
Cambodian
Cantonese
Chinese
Chumash
Dutch
Farsi
Filipino
Finnish
French
Fuchow
German
Greek
Hakka
Hawaiian
Hebrew
Hindi
Hmong
Hokkien
Hungarian
Ilocano
Irish
Italian
Japanese
Khmer
Korean
Laotian
Mandarin
Mixteco
Persian
Polish
Portuguese
Punjabi
Russian
Samoan
Scottish Gaelic
Serbo-Croatian
Somali
Spanish
Swahili
Swedish
Tagalog
Thai
Urdu
Vietnamese
Welsh
Wu
Yiddish
Is bilingual required at this site?
No
Yes
LOGISTICS
Will students need to do to check-in at the site?
Yes
No
Will students track their hours at the site?
Yes
No
Do students meet with site supervisor prior to their first service day?
Yes
No
Are students provided with computers or other materials they will need?
Yes
No
Will students be asked to buy anything?
Yes
No
Please List
Will they be reimbursed?
Yes
No
Will the student be driving a company car?
Yes
No
Who should the university contact at the CBO in case of an emergency?
Who should they recommend the CBO contact at the university?
RISK IDENTIFICATION
Please list any and all health and safety considerations at your site which apply to students serving:
Does the CBO provide a safety orientation?
Yes
No
Will students ever work unsupervised with clients?
Yes
No
Will the CBO request emergency contact information?
Yes
No
Please check any of the following applicable requirements or risks:
Background Check (e.g. fingerprinting/livescan, driving record)
Computer Literacy
CPR Certification
Driver's License
First Aid Certification
Health Check/Screening (e.g. temperature screening, COVID-19 test)
Must be 18 or older
Pre-Placement Training
TB Test
Vaccinations
Confidentiality Waiver
TOUR OF SITE
Does CBO have a building emergency exit plan?
Yes
No
Are evacuation signs clearly posted?
Yes
No
Are all exits clearly marked?
Yes
No
Is there any obvious damage to site that might create a hazard to occupants?
Yes
No
Are all work area and parking areas adequately illuminated?
Yes
No
PRIVACY RIGHTS
Are students allowed to take pictures or video?
Yes
No
Will the students need to sign any confidentiality waivers?
Yes
No
Check Box to Confirm:
I have met with a CPP representative to discuss the items above. The information is in this Site Visit Checklist is accurate.
Name of Organization Representative
Signature of Organization Representative
Clear signature
Date
Month
Apr
Month
Day
19
Day
Year
2024
Year
What Department, Program, or Faculty Member have you been working with to establish this partnership?
Submit