Online WBL Database Placement Form

You may customize this form to include only the fields that you use and to omit any fields that are always the same for your program or that you know without writing down.

WBLP Heading - Names and Email Addresses
Participant Name
Suggested format=lastname, firstname
Participant Email
Supervisor Name
Supervisor Email
Staff Name
Staff Email
Teacher or Other Contact Name
Teacher or Other Contact Email
Participant ID Information
Participant ID
(can be automatically filled in)
Activity/Program Details
Name of Activity
Work and Learning Program Elements
G=Connected to Planning Goals –
Work-based learning experience is coordinated with a college and career plan, EPP, Transition Plan or IEP, WIA service plan or other planning process / [ ] Yes-College and Career Plan
[ ] Yes-Other
[ ] No
[ ] Unknown
[ ]Not Applicable / Comments
R=Raising Graduation Rates - Participant was targeted/identified through a school initiative to raise graduation rates (incl. MCAS results, etc.). / [ ] Yes
[ ] No
[ ] Unknown
[ ]Not Applicable / Comments
O=Has Workshop or Classroom Component - A workshop, workshop series, class or academic program is connected to this work-based learning experience. If the experience includes several of these elements, please select the one highest on the list. / [ ] Yes-Internship Class
[ ] Yes-Work and Learning Academic Support Program
[ ] Yes-Internship Class
[ ] Yes-CVTE Program
[ ] Yes-Career Pathway Program
[ ] Yes-Work Readiness Workshop
[ ] Yes-Career Exploration Workshop
[ ] Yes-Workshops
[ ] Yes-Other
[ ] One-on-one coaching (not counted)
[ ] No
[ ] Unknown
[ ] Not Applicable / Comments
W=Has Work-Based Learning Plan
(Filled in automatically if in database) / [ ] Yes - In Database
[ ] Yes - In Database
[ ] Yes - In Word
[ ] Yes - Pen and Paper
[ ] Yes
[ ] Pending
[ ] No
Participant Information
Participant Date of Birth
Gender / [ ] Female [ ] Male
Race / [ ] American Indian or Alaska Native
[ ] Asian
[ ] Black/African American
[ ] Cape Verdean
[ ] Hispanic Origin
[ ] Native Hawaiian or Other Pacific Islander
[ ] White/Caucasian
[ ] Multi-race
[ ] Other
City of Residence
Zip Code
Low Income Household / [ ] Yes [ ] No
Participant Phone
Parent Name
Parent Phone
School
Current Grade
Year of Graduation/Class
Participant Career Area
Employer Information
Employer Name
Employer Address
Employer City, State, Zip
Employer Size / [ ] Small (Up to 49 employees)
[ ] Medium (50 to 499 employees)
[ ] Large (500 or more employees)
[ ] Unknown
Employer Type / [ ] Private
[ ] Public
[ ] Nonprofit
[ ] Unknown
Industry Cluster / [ ] Arts Media and Communications
[ ] Business
[ ] Construction and Design
[ ] Education
[ ] Environment Natural Resources and Agriculture
[ ] Health Care
[ ] Hospitality Tourism and Recreation
[ ] Human Services
[ ] Information Technology
[ ] Law Government and Public Service
[ ] Maintenance / Landscaping
[ ] Manufacturing Science Technology Engineering and Math
[ ] Marine Industries
[ ] Retail and Services
[ ] Transportation
Contact/Supervisor Additional Information
Supervisor Title
Supervisor Phone
Placement Information
Participant Job Title
Start Date
End Date
Hourly Pay
Hours Per Week
Type of Pay / [ ] Employer Paid [ ] Unpaid [ ] Subsidized / Sponsored Job
Program Enrollment
(check all that apply) / [ ] Connecting Activities
[ ] YouthWorks
[ ] WIA Youth
[ ] Cooperative Education
[ ] ESE Fund Code 596/597
[ ] ESE Fund Code 593
[ ] ESE Fund Code 626 / [ ] ARRA JAG
[ ] WIA Adult
[ ] DYS Bridging the Opportunity Gap
[ ] Other (specify) ______
Organization