CSUMB Site Self Assessment

Dear Community Partner,

The Community Site Visit Checklist is a tool for assessing the requirements, risks and basic safety factors of a site prior to student placement. This form should be filled out by a representative of the prospective organization. After submission, A CSUMB staff or faculty person will review the submissions, schedule a phone call with the prospective organization and/or conduct a site visit as necessary.

If you are working with a particular department, program, or faculty, please list them here

1. General Information

Name of Community Based Organization *

Main Contact First Name

Main Contact Last Name

Main Contact Job Title

Main Contact Email Address

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

Street Address

City

State

Zip Code

General Email Address

Website

Social media site

Please provide a brief description of your organization's purpose or mission

Which Organization type best describes your site? *

Please provide information about ongoing opportunities at your site

What kinds of things will students be doing?

Please check any of the following applicable requirements:

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

Do you prefer students speak a language other than English?

Is bilingual required at this site?

No

Yes

2. Logistics

What is the maximum number of students your site can accept?

students

Will training be provided to CSUMB students in the following areas? *

Check all that will be provided

Please describe any additional special training the CBO will provide

Site Tour

Has the organization given CSUMB staff and/or faculty a tour of facilities where students will be working?

Yes

No

Describe the Site

Is the site wheelchair accessible?

Yes

No

Has CSUMB staff and/or faculty member met organization staff who will supervise students?

Yes

No

Will CSUMB students be participating in off-site field trips?

Yes

No

Will the organization send CSUMB students to a sites other than at the primary address?

Yes

No

List addresses and descriptions of additional areas CSUMB students will serve:

Risk Identification

Does your organization have a formal volunteer process in place?

Yes

No

Are CSUMB students eligible to sign-up as volunteers?

Will CSUMB students ever work unsupervised with clients?

Yes

No

Will the CBO maintain CSUMB student’s emergency contact info?

Yes

No

Does CBO have general liability insurance policy?

Yes

No

Will the CBO cover worker’s compensation for CSUMB students?

Yes

No

Please list any and all health and safety considerations at your site which apply to students serving:

If TB test or background check is required, please indicate if it is paid for by the organization.

Are there specific health and/or safety risks associated with the student’s specific work assignment?

Is there any history of violence, environmental hazards or other health/safety risks on the site?

If yes please explain here

Describe any specific recommendations for precautions for students working at your site:

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