University of Tasmania
STUDENT CHECKLIST
This form is to be completed by all persons who wish to undertake student projects with the University
of Tasmania. The student, in association with the relevant Supervisor, must complete this form before
any work is commenced.
Name of student
Address
Telephone No.
Mobile No.
Emergency Contact
Telephone No.
Project Information:
Budget Centre
Biological Science
Project Title
Supervisor
Period of Project
From
To
Location of Project
Description of
Project
Has the student been fully briefed in relation to all aspects of the project? YES/NO
Medical Procedures:
If the student is participating in a field trip, then please complete Medical Disclosure and Authorisation
Form (attached)
For other student work:
Does the student have a pre-existing medical condition or injury that would preclude him/her from
carrying out all of the duties of the position? YES/NO
If the answer to the above question was YES, please provide details of the condition
……………………………………………………………………………………………..…..…………………
Is the student on any medication that could affect the operation of the project? YES/NO
Supervisor to be advised of any medication students are taking before they are allowed to undertake
the project.
If the answer to the above question was YES, please provide details of the condition
……………………………………………………………………………………………..…..…………………
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If a student is injured or has an accident during the operation of the project he/she must report it
immediately to his/her Supervisor. All injuries/accidents to be formally recorded by the Supervisor on
appropriate University of Tasmania Accident/Incident Report forms.
Facilities and Equipment to be used by Student (eg: Laboratories,, computers, workshop
equipment, field equipment etc.)
……………………………………………………………………………………………..…..………………….
……………………………………………………………………………………………..…..………………….
Has the student used the above equipment before? YES/NO
If the answer is YES, what experience does the student have (Supervisor to verify evidence of
experience, if appropriate):
……………………………………………………………………………………………..…..………………….
……………………………………………………………………………………………..…..………………….
If the answer is NO, what training needs to be undertaken before the student can use, operate, or
take part in the project:
……………………………………………………………………………………………..…..………………….
Safety Checklist: (To be completed by Supervisor and student. If the answer to any of the
following questions 1 to 6 is NO then a brief explanation is to be provided)
Has the student been made aware of:
1.
The University of Tasmania’s Occupational Health and Safety policies and procedures?
YES/NO Refer to https://secure.utas.edu.au/work-health-safety/whs-essentials
2.
All Risk Assessments relating to the project? YES/NO
3.
Safety Issues relating to project: …………………………………………………………… YES/NO
4.
Has safety equipment been issued to the student? YES/NO
5.
Does the student understand how to use and operate the safety equipment? YES/NO
6.
Does the student understand what action to take in the case of an emergency developing while
doing the work? YES/NO
7.
Does the student have to drive to and from the project? YES/NO If Yes, complete Driver
Medical Disclosure Form and read Driving Authorised Vehicles Policy. Refer to
http://www.admin.utas.edu.au/hr/ohs/pol_proc/driving.pdf If the student is using a private
vehicle, then the University’s Personal Accident Insurance Policy may not cover him/her.
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General Conditions:
The student must be advised that he/she is not covered by Workers Compensation Insurance
as he/she is not an employee of the University of Tasmania. However, students may be
covered under the University’s Personal Accident Insurance Policy for injuries sustained
whilst involved in authorised activities.
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Students will not receive any remuneration for student work.
Students must not sub-contract work to any other person.
Students must obey all reasonable requests made by the Supervisor. If a dispute arises, the
student should discuss the issue with the Head of School to which the project relates.
Students are to be supervised at all times, unless the Supervisor and student are satisfied that
the student is capable of safely working alone.
Students must comply with all security and office regulations in place at the location of the
project.
Student workers shall not represent themselves as employees of the University of Tasmania.
The University of Tasmania may terminate student work projects at its sole discretion.
Declaration:
I acknowledge that I have read and understand this document in relation to student work projects in
authorised activities on behalf of the University of Tasmania. I am required to abide by the
Ordinances and Rules of the University of Tasmania. That in the event of an injury which may entitle
me to make a claim under the Personal Accident policy, I am responsible for providing all relevant
details/documentation relating to the injury so as to facilitate the claims process. I have completed all
sections of the document with my Supervisor ……………………………………….. and I declare that to
the best of my knowledge the information given in this form is complete and true.
Student’s name:
……………………………………..
Student’s signature: ………………………………… Date:……………………………
* Alternative if the Student is under 18 years of age
Signature of Parent/Guardian:…………………..
Date:…………………………..
Signature of Supervisor:……………………….
Date:…………………………..
" I ______________________ (supervising academic) approve this person as a volunteer for the
project listed above
Signature…………………………
Date……………………………..
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MEDICAL DISCLOSURE AND AUTHORISATION FORM
The University is committed to continuously improving the management and standards of occupational
health and safety and in so doing we strive to protect the health and safety of our employees, students,
contractors and visitors.
In order to meet our duty of care obligations all employees, students, contractors and visitors who intend
to undertake field activities must complete the following information.
The University is committed to anti-discrimination practices and will provide reasonable accommodation
to allow individuals to participate in field activities where it does not compromise safety requirements.
TO BE COMPLETED BY PARTICIPANT - PLEASE PRINT IN BLOCK LETTERS
School/Section
Participant
Given Names / Preferred Name
Proposed Field
Activity
Residential Address
Personal Details
Date of Birth:
Medicare Number:
Emergency Contact
Details
Contact Person
Name:
Relationship to Contact:
Phone: Work:
Home:
Mobile:
Alternative Contact
Name:
Relationship to Contact:
Phone: Work:
Home:
Mobile:
Known allergies
Known Medical, Physical
conditions Dietary or
religious
requirements
Current Medication and
dosage
Medical Practitioner
Name of Doctor:
Phone No:
Declaration
I (full name)
declare that I have read this Form and that I have completed it
to the best of my knowledge and ability, disclosing all relevant facts as they are known to me. I also undertake to
advise my Field Activity Supervisor/Course Coordinator should my circumstances change during my
employment/study/contract that would change the answers provided above.
I authorise the Supervisor in charge of the field activity to consent to my receiving medical or surgical treatment as
may be deemed necessary in the event that I am unable to communicate.
Signature
Name in Print
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Date