##FromAddress##
Work Experience Request
##ContactTitle## ##ContactFirstName##
##ContactSurname##
##EmployerName##
##JobAddress##
Job ID: ##JobId##
Placement Dates: ##StartDate## to ##EndDate##
This learner will work the following:
##WorkingDays##
Learner must have an interview in person or by
telephone.
Dear ##ContactTitle## ##ContactFirstName## ##ContactSurname##
I am writing to you to request a work experience placement for ##StudentFirstName## ##StudentSurname## as
a/an ##JobTitle## with your organisation. Details of the learner are given below, including any known individual
factors which may influence the activities and restrictions for the young person.
Please can you sign and return the attached confirmation by email, fax or in the envelope provided as soon as
possible.
Learner Details
Name: ##StudentFirstName## ##StudentSurname##
DOB/Age at time of placement: ##StudentDOB##
Gender: ##Gender##
School Details / Placement Details
Name: ##SchoolName##
Teacher Contact: ##SchoolCoordinator##
Title: ##JobTitle##
Job Number: ##JobId##
Placement Dates: ##StartDate## to ##EndDate##
Known Factors
##KnownFactors##
##ReturnInstructions##
Yours Sincerely
##StaffUserFirstName## ##StaffUserSurname## ##StaffUserJobTitle##
##StaffUserEmail##
Please retain this sheet for future reference
Employer Work Experience Confirmation
Employer: ##EmployerName##
Job Number: ##JobId##
Learner: ##StudentFirstName##
##StudentSurname##
School: ##SchoolName##
If you are able to accept this learner, LEBC will be in touch shortly to arrange a brief meeting with you to
ensure the information held on our database about your organisation is both accurate and satisfactory. I
will send you appropriate confirmation paperwork.
Please tick as applicable and sign below:
Yes, I am able to accept the learner.
No, I cannot accept the learner for the data specified but I would like to continue with Work Experience.
Please can you confirm your email address: _______________________________________________
Employers Statement
As a representative of ##EmployerName## I agree to take on work placement on ##StartDate## to
##EndDate##. I have read and understood the enclosed placement description and all details provided and will
complete a specific risk assessment for the learner after the learner has made contact.
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.
Name: _____________________________________
Position: __________________________
Signed:_____________________________________
Date: _____________________________
PLEASE NOTE THIS CONFIRMATION FORM DOES NOT CONSTITUTE A LEGAL AGREEMENT.
Induction Checklist
We strongly recommend that for your own records a signed induction checklist should be kept for a
minimum of 3 years
Learner Name: ________________________________________________________________________
Things to do before work experience
Planning
Has the learner attended their interview?
Tick Initials
Has a learner specific risk assessment been undertaken e.g. consideration given for medical/health
conditions, disabilities and learning difficulties?
Work experience contract signed and returned to the school?
Are all relevant staff aware the learner is coming?
Have all relevant staff been briefed on safeguarding?
Is adequate and appropriate supervision arranged?
Who will be responsible in the absence of the planned supervisor?
Has a schedule of activities been identified for the learner?
Are all planned activities suitable for the learner?
Is Personal Protective Equipment available? Will it be available in suitable sizes?
Who will meet the tutor who monitors the visit?
Is there an emergency contact number available for the school/college?
Is there an emergency contact number available for the parent/guardian?
To be completed at the start of work experience
General Information
Organisation background and the role of the learner whilst on placement
Tick Initials
Introduction to key staff (safety/first aid)
Tour of premises including fire escape route and assembly point(s)
Shown staff/refreshment facilities
Notice boards and appropriate signage (location and purpose)
Health & Safety Information
Introduction to organisations Health & Safety Policy and procedures
Tick Initials
Explanation of risk assessments – organisations and learner specific
Safety literature
Prohibited areas/equipment
Safe working systems
Introduction and training to machinery that may be used
Housekeeping/tidiness/smoking policy
Manual handling/lifting
Dangerous substances
Protective clothing and safety equipment - usage
Hygiene
First Aid facilities & accident procedures
Emergency procedures
Confidentiality
Supervisor:_________________________________ Learner:_______________________ Date:__________