Form 244-4
Off-Site Work-Based Learning Placement
Teacher Health and Safety Orientation Checklist
Insert School Name,
Address, Town, Sask., Postal Code
Phone: (Number) Fax: (Number)
email address if applicable
Reference
AP 244 Off-Site Work-Based
Learning Placement
Revised
September 22, 2014
Level
School
Submit to
CWEX Teacher
When
Prior to Beginning of Placement
Course Name
School Name
Business/Organization Name
Date Visited
Health and Safety Hazard Checklist
Is the employer willing to discuss any potential hazards for the student while on the
potential work placement?
Identification of Hazards
Are any potential hazards identified in your visit?
If yes, list the possible hazards are identified? Be as honest as possible here.
Yes
No
Yes
No
Observation of the Workplace
Based on your observations of the workplace, were any concerns you had about the
student’s safety resolved through your discussion with the employer?
Yes
No
Health and Safety Orientation
Will the employer use the Health and Safety Orientation Checklist provided?
Will the employer use a safety orientation program she/he has already developed?
Yes
No
Summary
If you are able to answer “Yes” to the majority of questions above, there is a strong
probability this placement will ensure the student’s health and safety. From a Health
and Safety standpoint, are you reasonably sure this workplace is safe?
Yes
No
Are you satisfied the employer will deal with the hazards in a way that will protect the
student?
Sun West School Division requires that employers carry appropriate levels of liability insurance prior to
participating in work-based learning placement of the given course. In signing below, the employer indicates
they pay into Saskatchewan Workers’ Compensation and/or adequate insurance policies are in place at the
above named business.
Employer’s Signature
Date
Classroom and/or CWEX Teacher’s Signature
Date
Document1
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