WORK-BASED EDUCATIONAL PLAN AND PROGRESS REPORT
Student’s Name:
Social Security Number:
Home Phone:
Birthday:
Student’s Career Objective:
School/Address:
Instructor:
School-to-Work Coordinator:
Phone:
Employer Site/Address:
Supervisor/Mentor:
4=Skilled
3=Moderately Skilled
Phone:
2=Limitedly Skilled
1=Unsuccessful
COMPETENCIES
PERIODS
WORK-BASED COMPETENCIES
0=No Exposure
GRADING
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4
5
1.
2.
3.
4.
5.
6.
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8.
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11.
12.
If additional space is needed, attach an extra sheet of paper.
(Parent/Guardian’s Signature and Date)
(Student’s Signature and Date)
(School Representative’s Signature and Date)
(Employer’s Signature and Date)
NOTE: It is the policy of the school district that no person on the basis of race, color, religion, national origin or ancestry, age, sex,
marital status, handicap, or disadvantage should be discriminated against, excluded from participation in, denied the benefits of or
otherwise be subjected to discrimination in any program or activity.
Adopted from the South Carolina Department of Education
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