FORM 267-A11a
Adopted
Last Reviewed
Review Date
January 2016
January 2021
DETERMINING ELEMENTS OF RISK
Workplace: _____________________________________________ Date:____________________________________
Name and Title of Workplace Contact Interviewed: ________________________________________________________
The gathering of information will assist in preparing students for this workplace. Refer to “How are Students Insured?” in
the Employers’ Handbook for details.
1.
Work Placements involving an element of risk
To adequately address the elements of risk a Co-op student may be exposed to, please consider the following four areas
of safety and indicate the potential risks in the particular workplace.
Physical Risks
Noise
Confined space
Working at heights
Slip/trip/fall hazards
Presence of/working with,
hand or power tools
Sharp edges
Other (specify)
Additional Notes
Physical Risks
Heat stress
Cold stress
Working with electricity
Vehicles
Machinery with moving parts
or mobile equipment
Radiation
Additional Notes
Biological Risks
Hazardous bacteria or
viruses
Saliva
Mould
Fungus
Human/animal waste
Additional Notes
Biological Risks
Blood
Additional Notes
Chemical Risks
Chemicals
Cleaners
Fire/burning
Air pollution
Compressed gas
Other (specify)
Additional Notes
Chemical Risks
Solvents
Fumes
Petroleum
lead
asbestos
Additional Notes
Ergonomic Risks
Heavy lifting
Pushing or pulling
Twisting
Extended periods of standing
or sitting
Repetitive tasks
Additional Notes
Ergonomic Risks
Additional Notes
Hepatitis
Animal/insect bites
Needles
Other (specify)
Form 267-A11-a: Determining Elements of Risk
Bending
Moving people
Working at a computer
Other (specify)
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Social-Emotional Risks
Occupational, mental health stress that can be
associated with working in hospitals, long-term
care facilities, funeral homes, shelters, police or
workplace violence, working alone of in isolation,
etc.
Additional Notes
2. Driving a vehicle
The school board does not encourage students to be driving vehicles on placement business. A separate, written
consent is mandatory where a Co-op/experiential learning student is required to drive on placement business. If
required, form (F5) must be completed. It is important to note that the School Board insurance provides no
automobile liability insurance for Co-op/experiential learning student drivers.
will
will not
require a student to drive company/personal vehicles
3. Passenger in a vehicle
The driver of a student during a co-op/work experience program is deemed to be on the business of the host
employer. The School Board takes no responsibility for screening the driving record of the employer or employees
who may drive students. Adequate insurance coverage is the responsibility of the vehicle owner in which the student
is a passenger. If required, form (F1) must be completed.
will
will not
require a student to be a passenger in a vehicle during placement
4. Additional documentation or proof of testing
The following testing may be required at some placements. Please check the boxes which require a Coop/experiential learning student to provide proof of testing.
Vulnerable Sector Check required for day cares, nursing homes, etc.
TB Testing–required for day cares
Hepatitis B–required where the learning plan indicates potential contact with blood or saliva e.g. Ambulance
attendant assistants, dental assistants, patient care assistants in hospitals or nursing homes, medical lab
assistants, and classroom assistant, where the learning plan involves potential exposure to saliva or blood
Rabies–these shots are not required by the Board of Education but parents may wish to seek a doctor’s advice.
5. Personal Protective Equipment required by a placement
Hard Hat
Student buys
Employer provides
Safety Boots
Student buys
Employer provides
Eye Protection
Student buys
Employer provides
Hearing Protection
Student buys
Employer provides
Gloves
Student buys
Employer provides
High Visibility Clothing
Student buys
Employer provides
Other (specify) ________________________________________________________________
Employer’s Signature: ________________________________
Form 267-A11-a: Determining Elements of Risk
Date: ___________________
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