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Professional

By Vincent Richardson,2014-12-06 12:57
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Professional

    MCCCD Professional Staff Internship Program

     Application

    Internship Mentor Agreement & Notice of Leave

    Applicant’s Name: Employee ID #

    Job Title: Grade: Step:

    Work Phone: Permanent Board-Approved Date:

    Work Calendar: Select One Location : Select One Work Load: Select One

    Internship Proposal Title: Internship Location Select One Department:

    Internship Begin Date: End Date: FY Information subject to verification

    Have you been approved previously for a PSA Internship? Yes No If Yes, when?

    Primary Mentor’s Name : Supervisor’s Name:

    Primary Mentor’s Phone: Supervisor’s Phone:

    *****************************************************************************************************

     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.

     1) _____________________________________ Select Location

     Signature of Mentor (Primary) College

     2) _____________________________________ Select Location

     Signature of Mentor College

    *****************************************************************************************************

     NOTICE OF LEAVE

    To the applicant: Please sign this form to signify your intent to apply for an Internship leave of absence. Forward the

    form to your immediate supervisor for 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 leave of absence. These signatures do not indicate

    approved placement in the PSI 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:

     New (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 PSI committee determines that your employee will be awarded an internship leave of absence,

    you will be asked to sign a PSA Internship Leave Authorization Agreement.

    ; The District Office will provide replacement salary funds (including benefits) according to the PSA

    policy Appendix C.7.. For any questions regarding the replacement funds process contact

    Professional Growth Coordinator @ 480-731-8308.

    Signature of Supervisor Date

     Signature of College President/Vice Chancellor Date

     1

    PSI is a division of the Professional Staff Association

    The Maricopa Community College District is an EEO/AA Institution

    Revised 11/19/2013

    MCCCD Professional Staff Internship Program

     Application

Proposal

    This form is designed to provide you with guidelines for developing your proposal. Every section of this

    proposal will be rated for evaluation purposes.

    1. Internship overview

    ; Provide a brief summary of proposed Internship project. Please address the following:

    ; Why you want this opportunity

    ; What you will be doing (include description of your key responsibilities as an intern)

    ; How the experience will move you forward in your professional growth/performance

    and talent management.

    ; Contribution(s)/benefits your Internship will make to MCCCD

    (Department/College/District)

    ; First preference will be given to the most unique and original ideas that meets the

    needs of MCCCD.

    Click here to enter text. You may copy/paste any content from another word document to reflect desired formatting. This text box will accommodate any amount of text. Delete these instructions.

    2. Goal

    ; State your goal in positive outcome-oriented terms that are consistent with the MCCCD mission

    and values statement.

    Click here to enter text. You may copy/paste any content from another word document to reflect desired formatting. This text box will accommodate any amount of text. Delete these instructions.

    3. Objectives and Activities Timeline:

    ; Please list each major objective you expect to accomplish in order to achieve your goal.

    ; Use precise numbers for time frames or quantities expected.

    ; Under each objective list activities that you will do in order to achieve the objective.

    ; Include the time periods for each activity.

    Click here to enter text. You may type using the below offered format, or delete all and copy/paste any content from another word document to have other formatting. Delete this example and instructions.

    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: ………………..

     2

    PSI is a division of the Professional Staff Association

    The Maricopa Community College District is an EEO/AA Institution

    Revised 11/19/2013

    MCCCD Professional Staff Internship Program

     Application

    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

     Vietnam era

     Disabled Veteran

     Handicapped

     3

    PSI is a division of the Professional Staff Association

    The Maricopa Community College District is an EEO/AA Institution

    Revised 11/19/2013

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