CVMA - Work-Based Learning Submission Form

School / Organization Name *

Program / Department *

(e.g. CAPS, WCC, HCC, UNI Applied Engineering, etc.)

Primary Contact Name *

Primary Contact Email *

Primary Contact Phone Number *

Role / Title *

Check All That Apply:

Job Shadow

Career Interview

Site Tour

Project-Based Learning (classroom or team project)

Internship

Registered Apprenticeship / Pre-Apprenticeship

Skills Workshop / Guest Speaker Request

Other (please describe in text box)

Other

Description of the Need / Ask

(1-3 sentences explaining the activity and objective)

Preferred Dates or Date Range

Preferred Time Commitment

One-time (1-2 hours)

Multi-day

Semester

Summer

Flexible

Number of Students Involved

Student Age Range / Grade Level

Specific Interests or Career Pathway

(e.g. welding, CNC, engineering, robotics, supply chain, logistics, maintenance tech, business/marketing for manufacturing, etc.)

Does the activity require equipment, space, or supervision from the manufacturer?

If yes, describe.

Learning Outcomes or Goals for Students

Relevant Coursework and/or Safety Training the Students Have Completed

(optional but helpful in manufacturing - skills readiness varies dramatically)

Examples: PPE training, CAD, blueprint reading, machining, shop class, OSHA 10, etc.

Does the student require any accommodations?

If Yes to Accommodations, Please Describe

Is the student covered under school liability insurance?

Anything else to add?