Fr. Michael Goetz Secondary School

330 Central Parkway W., Mississauga

905-277-0326

STUDENT INFORMATION   Student:                                                                               Date:    Related Course (s):                                 Course Code (s):                                                          Type of Course(s):                                                        Credit Value(s):                        4                                                Ontario Curriculum:      Ontario Secondary Schools, grades 9-12: Program and Diploma Requirements

PLACEMENT INFORMATION Job Title:         Placement:        Address:           Placement Supervisor:                                                            Telephone:   Fax:                                                                                          E-Mail:

SCHOOL INFORMATION Teacher:                                                                                  Telephone: 905-277-0326 ext.   Fax:      905-615-1524                                                             E-Mail:

Classroom Component: (includes Pre-Placement, Integration, Independent Study Project)
Student Expectations	Demonstrations of Learning
Job Readiness	Apply for and obtain co-op placement through interview Produce applications, resumes, cover letters
Health and Safety	Adhere to health & safety practices at placement
Reflective Learning	Reflect on and analyze placement experiences
Rights and Responsibilities	Be open minded and respectful of cultural diversity Contribute to harassment-free environment Maintain confidentiality

Tie-Back Course 1_______________________________
Expectations from Related Course(s):	Demonstrations of Learning

Specific Placement Expectations

Tie-Back Course 2_______________________________
Expectations from Related Course(s):	Demonstrations of Learning

Specific Placement Expectations

Student’s Name: ________ ________________________________________________

Accommodations/Modifications (as per student's IEP)
Overall Training and Orientation	Date(s)/Time Frame
WHMIS Training General Workplace Orientation: tour of the workplace, location of fire extinguishers, first aid stations, fire exits, evacuation procedures, MSDS’s, staff bulletin boards, etc. Other training required by the workplace or identified by the assessment process:

                                                                                                                N-Needs Improvement  S-Satisfactory  G-Good  E-Excellent

Evaluation 1	Date:	Learning Skills	N	S	G	E
Supervisor's Comments: (strengths, areas for improvement		Works independently
		Teamwork
		Organization
		Work Habits
		Initiative
		Student's Comments:
Supervisor's Signature:		Student's Signature

Evaluation 2	Date:	Learning Skills	N	S	G	E
Supervisor's Comments: (strengths, areas for improvement)		Works independently
		Teamwork
		Organization
		Work Habits
		Initiative
		Student's Comments:
Supervisor's Signature:		Student's Signature

Level 1	Level 2	Level 3	Level 4
Passable but below the standard acceptable	Moderate but approaches the standard	Good – Very Good	Outstanding
50%n – 59%	60% - 69%	70% - 79%	80% - 100%
1-     1        1+	2-      2       2+	3-     3        3+	4-       4        4+