Internship Mentor Agreement & Notice of Leave

Applicant’s Name: / Employee ID # Work Phone:
Job Title: / Grade: Step:
Work Location : Select OneCGCCDSSCEMCCEMCC SCGCCGWCCGWCC SCMCCPCPVCCRSCSCCSMCC / Classified Staff Service Date:
Internship Location: Select OneCGCCDSSCEMCCEMCC SCGCCGWCCGWCC SCMCCPCPVCCRSCSCCSMCC Department: / Begin Date: End Date: FY
Internship Proposal Title:
Have you been approved previously for a CS Internship? Yes No If Yes, when?
Mentor’s Name : / Supervisor’s Name:
Mentor’s Phone: / Supervisor’s Phone:

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MENTOR AGREEMENT

To the mentor:

Please sign this form to signify your agreement to serve as a mentor for this applicant and abide by the evaluation process.

______
Signature of Mentor & Printed Name College

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NOTICE OF LEAVE

To the applicant:

·  By signing this form, you affirm intent to apply for CSII Leave. Further, you have read, understand, and will follow CSII Information & Guidelines. Forward the form to your immediate supervisor for his/her signature.

·  If you are awarded CSI Leave, you will be required to:

Sign a CSII Leave Authorization Agreement with the District, which outlines the conditions and stipulations of the leave.

·  Forward the form to your immediate supervisor and College President/Vice Chancellor for their signature.

Signature of Applicant Date

To the supervisor:

Please complete the replacement plan below, so the backfill funds could be properly allocated when applicant is approved for PSI, and sign this form to signify that you were notified by your employee about their intent to apply for an Internship. These signatures do not indicate approved placement in the CSI Program, only to proceed with the project idea.

Replacement Plan (check all that apply)

Internal (OSO/OYO) employee that will be placed on applicant’s current grade - step 2 or higher

Other (i.e. Administrative Temporary Reassignment for talent management & cross-training),
please describe:

External (OSO/OYO) employee that will be placed on applicant’s current grade - step 1

A temporary worker will be employed under the Request for Personnel Services (RPS) policy

No replacement will be necessary (backfill funding not applicable)

Please Note:

·  If the CS PG committee determines that your employee will be awarded an internship leave of absence, you will be asked to sign a PSII Leave Authorization Agreement.

·  MCCCS will provide replacement salary funds (including benefits) according. Funds are transferred after a replacement(s) has been hired and paperwork processed within two months of the beginning of the CSII leave. Unused funds remain in the CS Professional Growth account. It is the responsibility of the employee department to initiate the transfer of funds by contacting the Professional Growth Coordinator @ 480-731-8308 with the name, MEID of the applicant’s replacement, and the account number in which to transfer funds. If no contact is made by the supervisor within the listed timeframe, the funds will be forfeited with no recourse.

Signature of Supervisor & Printed Name Date

Signature of College President/ Designee Date


Proposal

Every section of this proposal will be rated for evaluation purposes please refer to CSII information and Guidelines for detailed rubrics information. Please limit information to no more than one (1) page for each category, for total of three pages

1.  Internship overview

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2.  Goal

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3. Objectives and Activities Timeline:

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Format example:

Objective 1: State First Objective Time Frame: Begin Date-End Date

Activity 1: State first activity Time Frame: Begin Date-End Date

Activity 2: State second activity Time Frame: Begin Date-End Date

Objective 2: ………………..

Affirmative Action Data

(Submit only one copy with your proposal)

Maricopa Community Colleges abides by all state and federal nondiscrimination

and equal opportunity requirements.

Affirmative Action Administrator

Maricopa Community College District

2411 West 14th Street

Tempe, AZ 85281-6941

Based upon federal reporting requirements, with which Maricopa Community College District is attempting to comply, we are requesting that you provide us with the information requested below. This information will be used for statistical purposes only, and will be retained independent of your proposal. In this regard, the materials for selection of candidates will neither change nor impede your receipt of favorable consideration.

Although your submission of the requested information is optional, your cooperation in this matter will be most helpful to the Maricopa Community College District.

Name:

Internship Proposal Title:

Female

Male

White

Black

Asian or Pacific Islander

Hispanic

Native American

Alaskan Native

Armed Forces Medal Veteran

Disabled Veteran

Recently Separated Veteran

Active Duty Wartime

Other Protected Veteran

I prefer not to self-identity at this time

Disabled

The Maricopa Community College District is an EEO/AA Institution 1

Revised March 9, 2017