Work Experience Arrangement Form - Victoria State Government

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Work Experience
Arrangement Form
Education and Training Reform Act 2006 – Ministerial Order 382: Work Experience Arrangements (Schools)
STUDENT DETAILS
Surname
First Name
Birth Date
/
/
School Name and Address
Postcode
Telephone
Work Experience Coordinator
Student Year Level
IN CASE OF AN EMERGENCY, THE EMPLOYER SHOULD CONTACT THE STUDENT’S PARENT OR GUARDIAN AND THE WORK EXPERIENCE
COORDINATOR:
Name (Parent/Guardian)
Address
Postcode
Tel. (Home)
(Work)
(Mobile)
Emergency contact (Name and Tel.)
PRIVACY INFORMATION: The information provided on this form is for the administration of Work Experience Arrangements only and is not to be
used for any other purpose. Health information will be provided if the Student has a medical condition or requires medication that may be relevant
to their placement. This information must be kept confidential.
WORK PLACEMENT DETAILS
Employer (business) name
Tel.
Business address
Postcode
Employer email address ___________________________________________________________
Type of industry
Primary activity at workplace
Student’s work location address
Postcode
Workplace contact person
Supervisor
Activities the student will undertake (if insufficient space, attach separate sheet)
Work Experience hours
am / pm, to
am / pm; on
Monday
Tuesday
Wednesday
Thursday
Friday
from (commencement date)
to (completion date)
Total number of days
Rate of payment $
per day ($5.00 per day minimum)
EMPLOYER ACKNOWLEDGEMENT (Employer to sign)
I,
[name of individual, or on behalf of the Employer if Employer is an incorporated body] agree that:
1. I understand occupational health and safety legislation and standards relevant to the conduct of my undertaking and will comply with these laws and
standards with respect to the Student as if the Student were my employee.
2. I will identify all hazards relevant to the conduct of my undertaking and will assess and control all related risks. If I have not controlled all related risks I will
inform the school of this fact prior to the Work Experience Arrangement commencing.
3. I have read and understood the Department of Education and Training Work Experience Guidelines for Employers. I will ensure that required planning,
induction, supervision and safe systems of work are provided for the Student to maintain a safe and healthy Work Experience Arrangement at all times.
4. I will consider and take into account the competency, maturity and physical capabilities of the Student in relation to all activities he or she will undertake. The
Student’s program of activities will be planned and carried out with these considerations in mind.
5. I will nominate a Supervisor (or Supervisors) of the Student who will be responsible for ensuring that my obligations as the Student’s Employer are carried
out.
6. I will provide appropriate information, training, instruction and supervision to the Student in respect of occupational health and safety and will provide any
equipment and/or clothing which is required to comply with my duty of care toward the Student.
7. I will ensure that the Work Experience is undertaken in a non-discriminatory and harassment free environment.
8. I will permit access to the workplace and contact with the Student by the Principal or the Work Experience Coordinator at any reasonable time during the
Work Experience Arrangement.
9. I will ensure that the Work Experience Arrangement is not used as a substitute for the employment of employees or the engagement of contractors and the
payment of appropriate wages or fee for services to employees or contractors respectively.
10. I will ensure that the maximum number of students in the workplace does not exceed one Student for every three employees.
11. If I have sought to engage more than the permitted number of Work Experience Students, I confirm that direct supervision will be provided for all Students.
12. Where the Principal has disclosed any necessary health information in relation to the Student I confirm that I will maintain the confidentiality of that health
information and only disclose this information to another party if treatment is required for a known medical condition or in the case of a medical emergency.
13. I will notify the Work Experience Coordinator as soon as is possible if the Student is absent, injured or becomes ill in the course of undertaking the Work
Experience.
14. I will consult with the Principal if I consider it necessary to terminate the Arrangement before the specified time.
15. I will advise the Principal if the industry to which this Arrangement relates includes potential exposure of the Student to scheduled carcinogenic substances
and/or other hazardous substances as defined in the Occupational Health and Safety Regulations 2007.
If the Student is a Child (under 15 years of age):
16. I confirm that I have obtained a Child Employment Permit and that any Supervisor has a current Assessment Notice and provide certified copies of these to
the Principal.
17. I will advise the Principal immediately if there is a relevant change in circumstances with respect to a Supervisor as specified in section 20(2) of the Working
With Children Act 2005 (Vic) including, if the Supervisor is charged with, convicted of or found guilty of a relevant offence, becomes subject to reporting
obligations, an extended supervision order, supervision order, detention order or if a relevant finding is made against the Supervisor.
18. I will notify the Principal immediately if a Supervisor is issued with an interim negative notice or a negative notice within the meaning of section 3 of the
Working with Children Act 2005.
I understand and accept the responsibilities set out above. Following the Principal’s review of these details, I understand that he or she will determine whether
or not the Student will undertake the Work Experience Arrangement proposed here.
Signature
Date
/
/

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