Education Work Survey

EDUCATION WORK SURVEY

Purpose: This survey collects current academic and work-related information to determine suitability for on-campus employment, work-study placement, internships, and referral to department supervisors. Information provided will be used for recruitment, placement, and eligibility determinations and will be treated in accordance with institutional privacy policies.

Student Information

Date of Birth:    Student ID:    Grade / Program:

Academic Status

Expected Graduation Date:    Current GPA:    Credits Completed:

Employment and Work Experience

Have you held campus employment previously?   Yes    No

Position / Title:    Start Date:    End Date:

Skills, Certifications, and Training

Check all applicable skills and certifications:

Computer / Office software    Data analysis / statistics    Tutoring / Mentoring    Laboratory techniques

CPR certification    First Aid    Security clearance / background check on file

Availability and Preferences

Desired average hours per week:

Days available (check all that apply):
Mon   Tue   Wed   Thu   Fri   Sat   Sun

Typical available time each day: From to

Preferred employment type:   Paid work-study   Internship   Volunteer   Part-time employment

Emergency Contact and Medical Information

Relationship:    Phone:

Authorizations, Certifications, and Acknowledgments

Certification: I certify under penalty of institutional sanction that the information provided on this survey is true and complete to the best of my knowledge. I understand that falsification or omission of material facts may result in disqualification from employment or disciplinary action.

Consent to Verify Records: I authorize the institution to verify my academic standing, enrollment status, GPA, and prior employment history as needed for placement and eligibility determinations.

Background Check: I understand that certain positions require a background check and I consent to the institution conducting such checks when required by position or department policy.

Privacy and Use of Information: The information collected on this form will be used only for employment and placement purposes and will be retained in accordance with institutional recordkeeping policies. Access will be limited to personnel with a legitimate need-to-know.

Acknowledgment of Policies: I have read and acknowledge the institution's policies regarding student employment, nondiscrimination, and workplace conduct. I agree to comply with applicable policies and department directives if offered a position.

Additional Information

By signing below, I attest that I am either the student named above or the student's parent/guardian if the student is under the age of majority, and that I have read and agree to the certifications and consents contained in this survey.

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