Work Experience Agreement
Job ID: ##JobId##
Date: ##TodaysDate##
Please retain this document until the learner has made contact and then complete if appropriate, sign &
return to the school via the learner or by post. Thank you.
Employer Details
##ContactTitle## ##ContactFirstName##
##ContactSurname##
##EmployerName##
##JobAddress##
School Details
Name: ##SchoolName##
Address:
##SchoolAddress##
Telephone: ##SchoolTelephone##
Email: ##SchoolEmail##
Work Experience Co-ordinator:
##SchoolCoordinator##
Placement Details
Contact Name: ##ContactTitle##
##ContactFirstName## ##ContactSurname##
Contact Telephone: ##ContactTelephone##
Contact Email: ##ContactEmail##
Supervisor Name: ##SupervisorTitle##
##SupervisorFirstName## ##SupervisorSurname##
Placement Dates: ##StartDate## to ##EndDate##
Interviewer Name: ##InterviewerName##
Learner must have had an interview in person or
by telephone.
Learner Details
Name: ##StudentFirstName## ##StudentSurname##
DOB: ##StudentDOB##
Gender: ##Gender##
Tutor Group: ##TutorGroup##
Home Phone No. (Where applicable):
##StudentTelephone##
Please can we ask that you inform the school co-ordinator on the number above if the student does not
arrive within 30 minutes of the agreed time? In a serious emergency out of school hours, please contact
a responsible member from the school (senior member of staff) on 999 or the Local Authority Crisis Line
(out of office hours) 0116 2551606 (County) or 0116 2528899 (City).
Known Factors
Known Factors (including medical conditions / medication taken / learning difficulties / other relevant issues) :
School / College to complete with known factors/disclosures regarding the learner.
Employer please consider this information when completing boxes 4,5 & 6 (where appropriate). You may wish to
discuss further with the learner or the school/college.
_________________________________________________________________________________________
##KnownFactors##
Placement Description
Placement Description - ##JobTitle##
##LearnerTasks##
Requirements
##Requirements##
Clothing
##Clothing##
Hours of Work
##HoursOfWork##
This learner will work the following:
##WorkingDays##
The number of hours worked by the learner should not exceed 37 per week (standard 7-8 hour day)
Meal Breaks
##MealBreaks##
General Workplace Awareness Statements:
##AwarenessStatements##
Organisations Original Hazard Awareness & Control Measures Statement:
The content of this section has been taken from information you supplied at the last visit by an Employer
Assessor.
##RiskAssessment##
Employers Young Persons Specific Risk Assessment & Control Measures
Name of Learner: ##StudentFirstName## ##StudentSurname##
Include additional employer control measures considered at either acceptance / interview / after discussion with
learner (e.g. Learner to use photocopier only after training) in column 4 below. (Refer to Known Factors Section
on Page One)
1.
Hazards
Hazard
2.
Risks
Risk
3. Control Measures
Control Measures
4. Prohibited & Restricted Activities
Prohibitions
5.
Additional Information / Controls Identified for Learner Consideration:
or additional information / controls)
(Use this section to inform learner
Employers Statement:
As a representative of ##EmployerName## I agree to take ##StudentFirstName## ##StudentSurname##
(##TutorGroup##) from ##SchoolName## on work placement on ##StartDate## to ##EndDate##. I agreed the
placement description and have completed a specific risk assessment for the learner as required by Regulation
19 of the Management of Health and Safety at Work Regulations. I understand my responsibilities for
undertaking a learner specific risk assessment and have taken into consideration any factors identified, additional
tasks / control measures have been added where appropriate to this document following discussion with/meeting
the learner to ensure their health, safety & welfare whilst undertaking work experience with this organisation. I
confirm that the learner will be insured under the organisation's Employer Liability Insurance and a workplace
induction will be undertaken on the first day. By signing, I am confirming that this information is current and
correct.
Please tick this box if you are returning, in addition to this document your organisations own young person’s risk
assessment.
Signature: ______________________________________ Date: ________________________________
Print Name: _____________________________________ Position: ____________________________
(Please retain a copy for your records and return a signed copy of this contract to the school/college)
Learner Statement:
I ##StudentFirstName## ##StudentSurname## (##TutorGroup##) agree to the work placement if available and
have attended an interview/made contact with my placement. I have read and understand the Placement
Description and young person’s specific risk assessment, which I agree to abide by as well as the
organisations/site health and safety procedures. It is understood that I will be classed as an employee whilst on
work experience for the purpose of insurance and will abide by the legal requirements under the Health & Safety
at Work etc Act 1974. By signing this document and returning it to the school I am consenting to the placement
going ahead.
Signature: _______________________________________ Date: ________________________________
Parent/Legally Responsible Person Statement:
Being the parent (legally responsible person) for ##StudentFirstName## ##StudentSurname## (##TutorGroup##)
I have read the Placement Description and young person’s specific risk assessment for ##StudentFirstName##
##StudentSurname## and understand they must follow this risk assessment and the organisation/site health and
safety procedures. I can confirm that my son/daughter has attended an interview/made contact with the
placement. It is understood that ##StudentFirstName## ##StudentSurname## is classed as an employee whilst
on work experience for the purpose of insurance and will abide by the legal requirements under the Health &
Safety at Work etc Act 1974. I have provided information on all known factors that need to be considered by the
employer and agree to inform the school and employer if this information is incomplete and also to inform should
my son/daughter be unable to attend their placement. By signing this document and returning it to the
school/agency I am consenting to the placement going ahead. I addition I have discussed travel arrangements
with my son/daughter and identified that he/she will travel to their placement using the following mode of
transport - (please circle as appropriate):
Signature: _______________________________________ Date: _________________________________
Print Name: ______________________________________
Return the signed copy of this contract to the school