Ojt Form Againadas

Pangasinan State University
Urdaneta Campus
Urdaneta City, Pangasinan

ELECTRICAL ENGINEERING DEPARTMENT

CERTIFICATION

This is to certify that BRYAN O. ADVERSALO, a BACHELOR OF SCIENCE IN ELECTRICAL
ENGINEERING student has been fully evaluated and satisfied the 240 hours of his OJT training, met the
specific objectives set by our department for its respective Program and complied with the Guidelines for
Student Internship Program in the Philippines (SIPP) for all Programs with Practicum Subject.

Certified this ______ day of _____________ 20______.

ENGR. ALFREDO C. NIPAL
Department Chairman

R E C O R D F I L E

NAME:_______________________________________________________________
LAST FIRST MIDDLE
COURSE:_____________________________________________________________
CONTACT NUMBER:____________________________________________________
HOME ADDRESS:_______________________________________________________
EMAIL ADDRESS:_______________________________________________________

PARENT/GUARDIAN:____________________________________________________
ADDRESS: ____________________________________________________________
CONTACT NUMBER: ____________________________________________________

OJT COMPANY:________________________________________________________
COMPANY ADDRESS:___________________________________________________
CONTACT NUMBER:____________________________________________________
EMAIL ADDRESS:_______________________________________________________
URL:_________________________________________________________________

SUPERVISOR/HUMAN RESOURCE: _________________________________________
LAST FIRST MI
SUPERVISOR CONTACT NUMBER: __________________________________________
COVERAGE DATE OF OJT: FROM_____________________ TO ___________________
(DD/MMM/YY) (DD/MMM/YY)

DOCUMENTS Complied
PRE DEPLOYMENT Requirements
1. Record File
2. Student Trainees Personal History Statement
3. OJT Application Form.
4. Latest Resume or Personal Data.
5. Certificate of Grades for the last two semester from the Registrars office with campus official
seal.

6. Medical clearance
7. Drug Test
8. Good moral character.
9. Guidelines for student trainee.
10. Barangay clearance
11. All pictures in the forms should be recent, colored, 2x2, and in corporate attire.
12. Waiver from parent/guardian.
UPON APPROVAL OF COMPANY
1. Memorandum of Agreement (MOA).
2. OJT training agreement
3. Training Agreement and Liability Waiver for Overtime (OT).
4. Affidavit of Training.
POST OJT Requirements
1. Certification from the Department Chairman.
2. Certificate of Training Completion.
3. Student-Trainees Performance Appraisal Report
4. Photocopy of Daily Time Record.
5. Time Frame.
6. Trainees Weekly Report.
7. OJT Narrative Report.
8. OJT Training Supervisors Feedback Form.
9. Student-Trainees Feedback Form.

Recent 2x2 picture
OJT Form Student-Trainees Personal History Statement
Republic of the Philippines
PANGASINAN STATE UNIVERSITY
URDANETA CITY, Pangasinan

STUDENT TRAINEES PERSONAL HISTORY STATEMENT

Recent 2x2 picture
Student Information
LAST NAME: FIRST NAME: MIDDLE NAME:
AGE: SEX MALE FEMALE
HEIGHT: WEIGHT: COMPLEXION:
DISABILITY(IF ANY) Tel No.:

BIRTHDATE:

(mmddyy)

BIRTHPLACE:
CITIZENSHIP: CIVIL STATUS:
PRESENT ADDRESS: TEL NO.
PROVINCIAL ADDRESS TEL NO.
Family Background(if parents are deceased give data for the nearest relative and indicate relationship to
applicant)
FATHERS NAME: OCCUPATION:
MOTHERS NAME: OCCUPATION:
ADDRESS OF PARENTS: TEL NO:
GUARDIANS NAME: TEL NO:
SCHOOL INFORMATION
COURSE: YEAR LEVEL:
MAJOR: LENGTH OF COURSE:
DEPARTMENT: SCHOOL ADDRESS:
OJT Program COORDINATOR: TEL NO:

OJT Campus COORDINATOR: TEL NO:
MR. LOPEZ, Kenneth 0755682040
CAMPUS EXECUTIVE DIRECTOR TEL NO:
DR. ZENAIDA U. SUYAT 0755682040
In case of emergency, notify
NAME: RELATIONSHIP:
ADDRESS: TEL NO:

I hereby certify that the foregoing answers are true and correct to the best to my knowledge, belief
and ability,
Signed at:____________________________ Date:____________________________

____________________________________
Applicants Signature over Printed Name
OJT FORM STUDENT-TRAINEES FEEDBACK FORM

Republic of the Philippines
PANGASINAN STATE UNIVERSITY
Urdaneta City, Pangasinan

STUDENT-TRAINEES FEEDBACK FORM

Name of Student-Trainee: ____________________________________ Course: __________________
Name of Company: ___________________________________ Department: __________________
Date of Monitoring: __________________________________

1. My training is aligned with my field of specialization.

Strongly Agree Agree Neither agree or disagree Disagree Strongly disagree
2. My training is challenging.


3. I have opportunities for learning.


4. I am aware with the policies of the company.


5. I have positive working relationship with my supervisor and other employees of the company.


6. I am aware of the risks and hazards of my working environment.


7. My department is committed to ensuring the health and safety of its student-trainees.


Problems Met: ________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________

Other Concerns:
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________

_________________________
Student Trainees Signature

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Pangasinan State University

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