WORK EXPERIENCE PLACEMENT
AUTHORISATION FORM
WORK EXPERIENCE PERIOD:
DEPARTMENT:
PLACEMENT AUTHORISED BY:
Head of Department
SIGNATURE …………………………
DATE ……………..
TSM or SAM
SIGNATURE …………………………
DATE ……………..
Young Persons/Children undertaking work experience:
Emergency contact:
Name
Any known allergy, disability or pre-existing medical condition:
Name and Position of Responsible Person(s) who will supervise the above:
Name
Hazards that the Young Persons/Children MAY come into contact with
Y
Extremes of temperature (eg Liquid Nitrogen/ furnace)
Potential for exposure to human body fluids
Exposure to hazardous substances (eg solvents, liquids, chemicals, dust, fumes,).
Exposure to allergens or sensitisers. (eg Latex gloves, animals, insects, fish.
Exposure to infectious organisms (eg prions, legionella, mycobacteria)
Non ionising radiation
Manual handling
Repetitive action
Face to face contact with people, and potential confrontational situations
Description of any work activities the Young Persons/Children may participate in:
Issued:17th May 2006
Revised 22nd April 2008
Revised 28th March 2014
Page 1 of 2
Rev 1.0
Rev 2.0
Rev 3.0
N
WORK EXPERIENCE PLACEMENT
AUTHORISATION FORM
Control measures to be taken to reduce the risks from the above activities to an acceptable level
(include references to any applicable risk assessments) :
As the supervisor of the young person named in this document I declare that I have read, understood
and agree to abide by the School Procedures and Guidance SPG-40-14 titled Hosting children and
Young People on Work Experience
SIGNATURE…………………………………………………………..
Issued:17th May 2006
Revised 22nd April 2008
Revised 28th March 2014
Page 2 of 2
Date…………………………………
Rev 1.0
Rev 2.0
Rev 3.0