Completed by:
STUDENT WORK EXPERIENCE
__________________________
WORKSITESAFETY DOCUMENT
Date:
___________________________
Name of Student:__________________________ School:______________________________
The purpose of this form is to prepare students and job coaches to work safely at your work site.
All students participating in a work experience program are registered with the Department of Education
and are thereby covered by Workers Compensation.
A Career and Community Experiences Teacher or a Career Development Teacher will make regular visits
to the work placement sites because on-going communication between the employer and the teacher is the
best method of providing the student with a safe and meaningful work experience.
Company Name:
Phone:
Full mailing address:
Name of Student’s Direct Supervisor:
________________________________
Phone # of Student’s Direct Supervisor:
Name(s) of Alternate Supervisor(s):
□
Student Orientation: Student/Job Coach will receive an orientation in
emergency procedures (location of emergency exits and location of first aid kit).
Job Coach:_________________________
Placement Job/Task(s):
Record of Jobs/Tasks to be performed by student and any equipment the student will
be operating.
Task / job / equipment listing:
a) _________________________________________________________________
b) _________________________________________________________________
c) _________________________________________________________________
d) _________________________________________________________________
e) _________________________________________________________________
f) _________________________________________________________________
Refer to list of potential hazards for reference.
Are there potential hazards related to the student tasks identified?
□ No □ Yes
If yes, complete hazard specific training form.
Pembina Trails School Division, 181 Henlow Bay, Winnipeg, Mb., R3Y 1M7
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Completed by:
STUDENT WORK EXPERIENCE
__________________________
WORKSITESAFETY DOCUMENT
Date:
___________________________
Potential hazards
□
□
□
□
□
□
□
□
□
□
□
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Exposure to potential violence, harassment, robbery, equipment damage,
shoplifting, etc.
Working from heights (anything over 3m), use of ladders, scaffolding, etc.
Operation of mobile equipment such as forklifts, order pickers, scissor lifts,
company vehicles, etc.
Lifting / awkward postures / repetitive tasks, etc.
Working with or around chemicals or biological or infectious agents.
Regular or prolonged exposure to hot or cold conditions (such as molten metal,
freezers, refrigerators).
Dangerous, prohibited or restricted areas, tools or equipment.
Excessive noise, air quality or low lighting.
Machinery that has moving parts that require guards and lock-out procedures.
Power tools or equipment, such as, but not limited to:
o Tools: table saw, mitre saw, drills, sanders, lathes, belt / disc sanders,
drill press, jointer, radial arm saw, router, scroll saw, planer, others list
below.
o Kitchen equipment: meat cutting equipment, mixers, dishwashers, gas
ranges / grills, knives, hot surfaces, got grease, etc., others list
below.
o Warehouse: scissor lift, forklift, order pickers, compactors, exacto knives,
ladders, etc. Others list below.
o Lab equipment: hot water baths, microscopes, shakers, DNA sequencing
equipment, knives, gel sequencing, fume hoods, biological safety
cabinets, Bunsen burner, live tissue, etc., others list below.
o Farm equipment: dryers, tractors, augers, combine, seeders, tillers,
sprayers, trucks, swathers, etc., others list below
o Grounds keeping equipment: lawn mowers, compactors, rototillers,
sprayers, hedge trimmers, tree trimmers, trailers, blower, grass trimmer,
pressure washer, snow blower, aerator, window washing equipment, etc.,
others list below.
Entry into confined spaces such as: tanks, crawl spaces, pieces of equipment,
excavations, pits, etc.
Working alone or in isolation – includes driving to different worksites during their
work day.
Pembina Trails School Division, 181 Henlow Bay, Winnipeg, Mb., R3Y 1M7
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Completed by:
STUDENT WORK EXPERIENCE
__________________________
WORKSITESAFETY DOCUMENT
Date:
___________________________
Hazard Specific Training
Identified Hazard
Safety Training Required
Training provided by:
Protective measures required for tasks assigned
Personal Protective
Equipment
Required
daily or
occasionally?
Will training be
provided? If
yes specify
who.
Employer
will supply?
Client to
supply or
arrange?
Safety boots (green patch)
Safety shoes (steel toed only)
Other footwear:_________________
Safety glasses
Hearing protection (specify type):
Dust mask (specify type):
Respirator (specify type):
Gloves (specify type):
Protective clothing (specify what)
Safety Vest
Protective headwear (specify type):
Immunization (Specify what)
Pembina Trails School Division, 181 Henlow Bay, Winnipeg, Mb., R3Y 1M7
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Completed by:
STUDENT WORK EXPERIENCE
__________________________
WORKSITESAFETY DOCUMENT
Date:
___________________________
Workplace Training and Orientation
Identify Training Required
Training Provided by:
General Workplace Orientation and emergency
procedures
Tour of the workplace, location of fire
extinguishers, first aid stations, fire exits,
evacuation procedures, MSDSs, staff bulletin
boards, etc.
Workplace-Specific WHMIS Training
Job/Task Specific Training
Regular operating procedures, including use of any
safety devices, applicable lock-out procedures,
rules of use, etc.
Other training required by the workplace or identified by the assessment process:
1.
2.
Job Assignment Updates – when tasks assigned to student have been changed/added:
New Task / Job
Associated
Hazards
Required Personal
Protective Equip.
Pembina Trails School Division, 181 Henlow Bay, Winnipeg, Mb., R3Y 1M7
Training provided by
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