Health And Safety Questionnaire 632560

Appendix 5: Health and Safety Work Placement Module: Health and Safety Questionnaire Employer Section Under Health and Safety legislation placement providers/employers (the organisation) are responsible for controlling the risks to students’ health and safety. Students, while undertaking either paid employment or voluntary placement, are classed as employees and are therefore owed the same duty of care as full-time, paid employees. Please answer the following questions by circling the appropriate response and sign in the space provided. 1. Does the organisation have a Health and Safety policy? YES – Written Policy (required for an organisation with five or more employees) YES – Not written (for organisations with four or fewer employees) NO – Please provide reason __________________________________________________________________________________ __________________________________________________________________________________ _________________________________________________________________________________ 2. Will the student receive a Health and Safety induction at the start of their placement/employment? YES/NO 3. A) Are there any significant risks to the Health and Safety of the student in relation to the activities undertaken during the placement/employment? YES/NO B) If YES have written Risk Assessment and Control Plans been prepared to minimise the risks? YES/NO 4. Are the premises on which the duties of the student take place ed with an appropriate enforcement authority? a. YES – Local Authority Environmental Health b. YES – Health and Safety Executive c. No – Registration not necessary (please state reason) __________________________________________________________________________________ __________________________________________________________________________________ 5. Does the organisation have liability insurance covering the student that will be current for the duration of the placement/employment YES/NO (if YES please provide a letter from your broker/insurance company which identifies the level of cover and clearly states the dates for which the cover is valid) Name of Employer Position (Owner; Health & Safety Officer; etc.) Signed Date Student section overleaf

Work Placement Module: Health and Safety Questionnaire Student Section

Students undertaking Work Experience have the same Health and Safety responsibilities as other employees in the workplace. Responsibilities include taking reasonable care of their own Health and Safety and that of other people who may be affected by their actions, and cooperating with the employer in complying with their legal duties. Please read the following statement and sign the declaration below. I have read the HSE leaflet ‘Health and Safety Law’ and am aware of my responsibilities with regard to Health and Safety. I understand that I have an obligation to cooperate with the risk assessment process and so should declare any relevant medical condition or disability that may affect my health and safety (or that of others) during the placement activity.

Name (Please Print) Signed Student ID Date

Once completed by student and employer this form must be submitted to Rebecca Edwards at least 10 working days before any work experience is undertaken that will contribute towards the portfolio. A copy must also be included within the portfolio submitted for assessment.