Letter to Placement Employers – (Fill in and Return to UTM)
2015-16
PROCESS FOR WORKPLACE SAFETY AND INSURANCE (WSIB or PRIVATE) COVERAGE:
The Ministry of Training, Colleges and Universities (MTCU) has implemented a new streamlined process for students
enrolled in an approved Ontario University program which allows students to complete work placements as part of their
course in a program of study. The Workplace Educational Placement Agreement (WEPA) Form has been replaced by the
Postsecondary Student Unpaid Work Placement Workplace Insurance Claim Form. This form is only completed when
submitting a claim resulting from an on-the-job injury/disease.
The Postsecondary Student Unpaid Workplace Insurance Claim Form has been posted on the MTCU’s website at:
English Version or French Version
Please note that all WSIB or private insurance (ACE INA) procedures must be followed in the event of an injury/disease.
Universities will keep the original signed Letter to Placement Employers on file and ensure that Placement Employers
have a copy. Whether an organization has either WSIB or Private coverage for their own employees, eligible students
hosted at the organization are covered for either WSIB or Private insurance by the MTCU or the University.
Declaration:
By signature of an authorized representative here under we confirm our understanding of our responsibility to protect
Student Trainees from health and safety hazards in our workplace by providing a safe working environment, health and
safety orientation prior to exposure of hazards (attached checklist may be used) and appropriate supervision during
their placement. We also confirm our commitment to immediately report any workplace injuries or disease to the
student’s university and follow WSIB or ACE INA accident reporting procedures (see details page 2 attached).
Signature: ______________________________ Name: ________________________________
Title: ______________________________ Organization: _______________________________ Date: _______________
Placement Details:
Direct or Coordinating Supervisor (Print):
Title:
Department:
Phone:
Email:
Student Name (Print):
Student Phone:
Course #:
Student Email:
List usual Days and Hours student will be at Placement (ie, Mondays, 9am-5pm): _______________________________
This organization is a WSIB-covered workplace (Y/N) _____.
General duties of student (attach additional page if necessary) ie Marketing research and presentations:
If travel is required as part of placement duties, please describe: _____________________________________________
If placement exposes student to hazards, please describe:
Distribution:
1. Original of Declaration (this Letter to Placement Employers) with signature is to be returned to the University of
Toronto Mississauga (send back with student);
2. A copy is to be kept by the Placement Employer.
1
Letter to UTM Placement Employers (Page 2)
INSTRUCTIONS IN THE EVENT OF AN INJURY/DISEASE
In the event of an injury/disease involving a UTM student, the placement employer must complete, sign and send the
following forms to the Experiential Education Office to the attention of Catherine Laroche-Boisvert, Acting Experiential
Learning Officer: cat.laroche.boisvert@utoronto.ca within three (3) business days of learning of a work-related
injury/disease:
1. If the employer subscribes to WSIB – they will need to complete, sign, and send to Catherine the following forms
and contact her immediately:
•
U of T WSIB Student Accident Report
•
Letter of Authorization to Represent Employer
•
Postsecondary Student Unpaid Work Placement Insurance Claim
•
WSIB Form 7 Employer’s Report of injury/disease - Employers can access the form at: www.wsib.on.ca Detailed instructions and guidelines for completing Form 7 Employer’s Report of injury/disease are
included with the form.
2. If the employer does NOT subscribe to WSIB – they will need to complete, sign, and send to Catherine the
following form and contact her immediately:
•
ACE INA
•
Accident Report
For more information, please read the MTCU Guidelines at: MTCU Guidelines for Workplace Insurance.
LIABILITY INSURANCE
The University provides general liability insurance. A liability/comfort letter is available if the host organization requires
one. Please note that this is not mandatory.
Information and UTM related forms can be downloaded at:
http://www.utm.utoronto.ca/experience/experiential-learning-resources/important-formsand-links or by contacting:
Catherine Laroche-Boisvert
Acting Experiential Learning Officer
Office of the Dean, DV 3201E
University of Toronto Mississauga
3359 Mississauga Rd.
Mississauga, ON L5L 1C6
Ph: 905-828-5295 Fax: 905-828-3979
cat.laroche.boisvert@utoronto.ca
www.utm.utoronto.ca/experience
WSIB Administrator: Shannon L. Howes
Manager, Student Policy Initiatives & High Risk
Office of the Vice-Provost, Students & First-Entry Divisions
Simcoe Hall, 27 King’s College Circle, Rm. 221
University of Toronto
Toronto, ON M5S 1A1
Ph: 416.978.2083 Fax: 416.946.0678
shannon.howes@utoronto.ca
2