Work-Based Learning

Personalized Learning Plan

Student Name: Nicole

Placement date

Date: Placement Site:

WBL Coordinator: Angelia Ford

Up-to-date copies of the Safety Training Log and the Work-Based Learning Agreement must be kept on file both
at the work site and at the school for all WBL placements as required by Tennessee Child Labor Law and
consistent with the Department of Education’s WBL Policy Guide.

This packet is required for students earning credit through the Work-Based Learning: Career Practicum course or
other practicum courses for credit. It is recommended that students use this packet for all credit-bearing WBL
experiences to ensure compliance with the State Board of Education’s WBL Framework, with federal and state
child labor laws, and with the Department of Education’s WBL Policy Guide:

List the 2 (or more) courses the student has completed within their Program of Study:

1. Biology_____________ 2. Psychology

3. ______________________________ 4. ______________________________

Name of Elective Focus or CTE Program of Study: _______________________________

Verification of Worker's Compensation: Yes______ No ______

If the student is in a PAID experience, he/she must be covered by the employer's Worker's Compensation plan. In
instances where Worker's Compensation is not provided, the student MUST supply evidence of a personal
accident insurance policy.
 Personalized Learning Plan Part A: Long-term Goals and
Learning Objectives

PLANNING FOR WORK-BASED LEARNING

Consider your past experiences, interests, and future career and education goals to answer the questions
below.
What is your area of elective focus in high school?
social science

What are your plans for after high school?

i plan on attending college

Describe your future career goals:

I would like to become a veterinarian with my own practice

What kind(s) of education or training might you need after you graduate from high school?
To major in biology and on field experience you can get from simply volunteering to learn how to interact with
animals

What placement or capstone work-based learning experience do you hope to get?

I hope to get a better understanding of the work field

ONCE YOU HAVE IDENTIFIED A POSSIBLE PLACEMENT

How is this work-based learning experience aligned with your career goals?
AIt will allow me to have an internship at an animal hospital

What do you want to learn through this experience that will help you progress toward your long-term goal?
I would like to learn more information about animals and how veterinarians interact with them and the clients
What special projects or activities will help you practice important skills?
Getting hands on experience
Below is a list of skills that employers seek from their employees. Complete this section during the
WBL experience. Work with your teacher and/or employer to document the ways you practice
these skills through your experience. Also write down what evidence you can add to your
portfolio after the experience to show your skills!

(You can learn more about what kinds of activities and learning opportunities are available at
the workplace by doing an internet search and interviewing the employer if that is possible.
See the Pre- Experience Research Checklist and Informational Interview Guide.)

APPLICATION OF ACADEMIC AND TECHNICAL KNOWLEDGE AND SKILLS

LITERACY: Read and comprehend relevant academic and technical texts

Getting a better understanding of basic needs for domestic animals

My Experience:
At the clinic there is the option to board your pets at there. It allows the owners to attend whatever event they
have planned while knowing their animal is getting taken care of. I was able to help tend to the pets that were
staying there at the time i was there.

My Evidence:
 To better understand the equipment used

My Experience:
I was shown how to use some the equipment there. For example one of them has to be counterbalanced no
matter what, it allows for the slides to get the bacteria needed onto the slides.

My Evidence:
APPLICATION OF ACADEMIC AND TECHNICAL KNOWLEDGE AND SKILLS (cont’d)

Learn how some the body of works for domesticated animals

My Experience:
A dog become bloated due to get too much air into his stomach. This caused his stomach to twist up because a
dogs body does not hold the same parts to hold the stomach down. He got x rays taken then transferred to an er
in order to get surgery to fix his stomach. This allows me to understand the parts within a dog and how it works.

My Evidence

To understand the process of when animals get a check up

My Experience:
I walked in with the vets to examine an animal. Most vets start from head to the back of the animal. It is an easier
process and allows the vet to check the areas in the animal precisely. Afterwards the vet assistant or technician
takes the animal back to weigh and get a fece sample.

My Evidence:
CAREER KNOWLEDGE AND NAVIGATION SKILLS

UNDERSTANDING PATHS AND OPTIONS: Plan and navigate education and career paths aligned
with personal goals
To learn whether this is a career path i would enjoy

My Experience:
I learned that yes, i would enjoy this work area very much. The type of people who seem involved so far come
across as decent people. And being able to work with animals is very pleasant.
Learn what type of clinics you need to being able to help a variety of animals

My Experience:
I have seen snakes, guinea pigs, anda rooster. There has been a few other types of animals that came in. Animal
clinics usually specializes in a certain area, but it all depends on the vet.

My Evidence:
21ST CENTURY LEARNING AND INNOVATION SKILLS

Learn if animal hospitals offer more

My Experience:
A dog was getting his teeth clean. They offer dental cleaning, cutting nails, and other offers as well depending on
the clinic

My Evidence:

How to control a crazy animal

My Experience:
i got dragged by a dog, so one of the vtrs showed me putting the leash between the neck and ears helps get a
better control of the dogs.
My Evidence:

(the dog that pulled me)

How it is determine to see if the animal has a type of parasite

My Experience:
The best way to check for this is through feces samples then checking through a microscope
My Evidence:
WBL Safety Training Log
The following safety training log should reflect the training requirements appropriate for the student’s job description and align with the
required trainings of the business. According to Tennessee Child Labor Law and WBL Policies, this form must be kept up-to-date in the
personnel file at the workplace and at the school. Copies of the Safety Training Log and the WBL Agreement must be kept on file at the
school for five years after placement.

Student Name: Work Site:

Address: Address:
City/Zip: City/Zip:

Phone: Phone:
DOB: Workplace Mentor:

Student’s Responsibilities/Job Description:

Safety Training Topics* Trainer’s Name Location Date

Provid
ed
1.

2.

3.

4.

5.

6.

7.

8.

*If additional space is needed, attach an extra sheet of paper.

SIGNATURES
Student: Date:

Parent or Guardian: Date:

Endorsed Teacher: Date:

(When not the WBL Coordinator)
WBL Coordinator: Date:

Principal: School: Date:

 CTE Director: Date:
(or designated WBL Coordinator)
Workplace Mentor: Date:
Note: It is the policy of the school district that no person on the basis of race, color, religion, national origin or ancestry, age, sex, marital status,
disability, or disadvantage should be discriminated against, excluded from participation in, denied the benefits of or otherwise be subjected to
discrimination in any program or activity. This form is subject to monitoring by TDOE and/or TDOL&WD.
Work-Based Learning Agreement
According to Tennessee Child Labor Law and WBL Policies, this form must be kept up-to-date in the personnel file at the workplace and at
the school. Copies of the Safety Training Log and the WBL Agreement must be kept on file at the school for five years after placement.

Contact Information: Typical Weekly Work Schedule: Hours for

credit-bearing experiences must equate to a full-
Student Name: Click here to enter text. Student time equivalent course.
Address: Click here to enter text. Student Phone:
Day Time of Total
Click here to enter text. Student Date of Birth: Click
Work From Work
here to enter text. High School: Click here to enter
Hours
text.
To
School District: Click here to enter text.
Area of Elective Focus: Click here to enter text. Monday
Student Start Date: Click here to enter text. Tuesday
Wednesda
Company: Click here to enter text. Company y
Address: Click here to enter text. Workplace Thursday
Mentor: Click here to enter text. Mentor’s Phone: Friday
Click here to enter text. Saturday
Mentor’s Email: Click here to enter text.
Sunday

Average Weekly Hours: Click here to enter text.

Paid Position? Choose an item.
Select the type of experience that best applies:
Choose an item.

Career Area that best aligns to student experience (select one): Choose an item.
Workers’ Compensation Coverage: Choose an item.

Employability Skills: This student is participating in work-based learning for credit and will have the opportunity to
practice employability skills appropriate to the placement to prepare them for postsecondary education, future careers, and
life. As such, employers are asked to complete a survey of the student’s skills, which will be emailed from the Department of
Education.
● Application of academic and technical knowledge and skills
● Career knowledge and navigation skills
● 21st Century learning and innovation skills
● Personal and social skills

Verification: We, the undersigned, give permission for the above-named student to participate in the WBL program, and we
understand and agree to meet the requirements of the WBL Framework as provided in State Board of Education policy and in the WBL
Policy Guide provided by the Tennessee Department of Education. We verify the above information is correct and is consistent with
federal and state guidelines for work-based learning experiences.
Student: Date:

Parent or Guardian: Date:

Co-Signing or Endorsed Teacher: Date:

(When not the WBL Coordinator)
WBL Coordinator: Date:
 Principal: Date:

CTE Director: Date:

(or designated WBL Coordinator)
Workplace Mentor: Date:
Note: It is the policy of the school district that no person on the basis of race, color, religion, national origin or ancestry, age, sex, marital status, disability, or
disadvantage should be discriminated against, excluded from participation in, denied the benefits of or otherwise be subjected to discrimination in any
program or activity. This form is subject to monitoring by TDOE and/or TDOL&WD.
Work-Based Learning
Insurance and Emergency
Information

Student Name: Work Site:

Address: Address:

City: Zip: City: Zip:

Phone: Phone:

DOB: Grade: WBL Coordinator:

Allergic to Medication? □ No □ Yes If yes: list

medication(s): List any other allergies or medical problems:

Parent/Guardian Home

Phone:

Work

Phone: Cell

Phone:
Parent/Guardian Home

Phone:

Work

Phone: Cell

Phone:
Additional Emergency Contact Home

Phone:

Work

Phone: Cell

Phone:
Medical Alert: □ No □ Yes, If yes: additional

explanation: Insurance Company: Policy

#:
I consent for my child to receive medical treatment in case of injury or illness. The information provided is
accurate to the best of my knowledge.

Parent or Guardian Date

Student Date

WBL Coordinator Date

Principal Date

Supervisor Date

Note: It is the policy of the school district that no person on the basis of race, color, religion, national origin or ancestry, age, sex, marital
status, disability, or disadvantage should be discriminated again, excluded from participation in, denied the benefits of or otherwise be
subjected to discrimination in nay program or activity. This form is subject to monitoring by TDOE and/or TDOL&WD.