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Original to be held by the school

Copy 2: for the student

Student Placement Record

Copy 1: for host employer

Copy 3: for the parent or carer

Students Name:

School: Newtown H.S. of the Performing Arts Host Business:

Tick more than one if applicable:

HSC VET work placement

Work experience

Other

Accommodation away from home

Section 1: Student placement details

Start date

Finish date

Total number of days

Related course/activity

Students
starting time

Finishing time

Lunch break

Students total hours

Tick where relevant:

Block

One day per week

Split shifts

Details/Location between split shifts:

Host employer onsite address

Contact person
Phone

Mobile

Email

Student information
Name

Year (e.g. 10)

Students mobile no.

Medicare no.

Date of birth

Details below (or attached) of any adjustment, medication or medical condition (e.g. severe asthma, type 1 diabetes, epilepsy, anaphylaxis or
other severe allergy), disability, learning and support need or factors the school or employer should know:

Please tick where applicable:

I am at risk of an anaphylactic reaction and will carry an adrenaline auto-injector, e.g. EpiPen and relevant ASCIA Action Plan.
Yes No
The placement includes out of normal business hours, e.g. 6-9pm
Name of students emergency contact out of normal business hours
Parent/carer/other

Home Ph

Mobile

Work Ph (if relevant)

I have completed all pre-placement activities.

I am aware of my rights and responsibilities.
I understand my responsibilities during the placement to support
work health and safety in the host workplace. I know I must not do
anything to jeopardise the safety of myself or others.
I understand that if I feel unsafe during the placement I have the right
to not undertake the task and report the issue, as soon as possible.
I understand my safety is of the highest importance during the
placement and there are no negative consequences to me in
reporting health and safety issues to my school, the host employer
or to my parent(s)/carer.
I know I must contact my school if I have any concerns about
my placement.
I will inform both the host employer and my teacher as soon as
possible if I am unable to attend the workplace.

I know who to contact in case of emergency.

I am aware of the contents of the Privacy Notice on Page 3.
I will comply with all reasonable directions of the host employer
and their employees.
If I have access during the placement to business or personal
information which is private and confidential, I will not convey that
information to any person outside the host employers workplace.
I will not use any mobile devices to record conversations, video or
take photos without permission from the host employer or supervisor.
I will inform my supervisor and the school promptly of any injury or
accident that involves me.
Student signature
Date

Section 2: School details

School Newtown H.S. of the Performing Arts

Email [email protected]
School phone number (02) 95191544

Address 380 King Street Newtown NSW 2042

Front office hours 8.30am - 3.15pm

P.O. Box 785 Newtown 2042


Schools
nominated Ula George, Careers Adviser
contact, position
(02) 95191544 Ext. 111
and phone/mobile
details during normal Mobile: 0405628890
business hours

The school undertakes to ensure that:

the student is prepared for the workplace to optimise the students safety and achievement during their placement
the employer is provided with a copy of The Workplace Learning Guide for Employers
the students parents or carers are provided with a copy of The Workplace Learning Guide for Parents and Carers
if the placement involves accommodation away from home, additional preparation occurs and relevant documentation is completed and attached.
Page 1 of 4

Student Placement Record 2014

Students Name:

School: Newtown H.S. of the Performing Arts Host Business:

Section 3: Host employer details (This first section may be completed by the student)
Name of organisation or trading name
Address

Contact person

Position

Phone

Post code

Email

Mobile

Website

Fax

Location of placement (if different from above address)

Request is for: HSC VET work placement or

Work experience or

Other

Dear Host Employer:

Please complete all the following responses to give the school important information about the proposed
placement. This will assist the school to manage their duty of care to the student and your responses will
help you satisfy your relevant workplace obligations. You may wish to keep a file copy as a guide for any
future placements. Thank you.

Overview
Type of industry

Main activity

Approx. no. years in current operation

Approximate no. employees at proposed worksite

Government enterprise

Private enterprise

Self-employed

Other

Tick only if you have hosted school students for work experience or work placement in the last 12 months.

Supervision and student hours

Name of the experienced employee who will provide on-going supervision of the student. The supervisor would not be a trainee or an apprentice.
Supervisors name

Position

Students starting time

Lunch break

Tick where relevant:

Finishing time
Block

One day per week

Students total hours

Split shifts

Details

Please note: there are a number of hazardous activities which are prohibited for students undertaking placements. These are listed at:
Prohibited activities and activities that need special consideration.
Or see website https://www.det.nsw.edu.au/vetinschools/worklearn/ProhibitedActivities.html.

Description of the proposed placement in detail

Activities/duties to be undertaken by student

Any activities or tasks the student is not to undertake e.g. no-go areas, machinery or equipment that is too dangerous for new or young
workers to operate.

Indicate any risks to the student in the planned activities e.g. manual handing, repetitive activities, exposure to sun, chemicals, fumes, use of
particular tools or equipment, proposed horse riding or use of farm vehicles.

How will those risks be eliminated or controlled?

Special conditions e.g. clothing, footwear, equipment, pre-training, transport, multiple sites, routine car travel and individual student needs.

Continued next page:

Page 2 of 4

Student Placement Record 2014

Students Name:

School: Newtown H.S. of the Performing Arts Host Business:

Section 3: Host employer details (Continued from page 2)

Please tick if these are available to the student:

Essential:

Other:

first aid facilities

suitable toilet facilities

drinking water

lunch room

staff canteen

lockers

Host employer/workplace supervisor to complete the following declaration:

I have read The Workplace Learning Guide for Employers and am aware of the employers rights and responsibilities
outlined in it and the need to provide a safe and positive environment for the student, free from harassment
and discrimination.
I will provide planned learning and skill development activities appropriate for the student under the supervision of
myself or a capable and trustworthy employee briefed for the task.
I confirm that the activities assigned are suitable for the student and that WHS risks have been assessed and
managed in accordance with the requirements of the Work Health and Safety Act 2011 (NSW).
I will check any health care concerns with the student and ensure they and their supervisor know what to do in the
case of a medical event i.e. where the student will keep their medication, e.g. an adrenaline auto-injector-EpiPen.
I will consult and cooperate with the school and will notify the school immediately of any health and safety
incidents involving a student while on placement, including near misses, to enable the Department of Education
and Communities to fulfil its WHS obligations.
I will see that the student is first provided with a site-specific workplace induction and then with the appropriate
information, instruction, training, supervision (and personal protective equipment where needed) throughout the
placement.
I acknowledge that the student will not be paid in relation to the placement.
I will notify the school if the student is ill, injured, absent without explanation or behaving inappropriately.
I will notify the school immediately if I need to change sites, redirect students to another location or find asbestos
on the site.
I have read and understood the special responsibilities associated with working with children and young people
as detailed in the section related to child protection in The Workplace Learning Guide for Employers. I understand
students must report incidents to their school.
I am not aware of anything in the background of any staff member or other person who will have close contact
with the student that would preclude that staff member or person from working with children.
I have informed employees of their responsibilities when working with children and young people.
Tick this box if you wish the students school to contact you prior to the placement e.g. to provide you with
information about the student such as their experience, skill level, any adjustment required, or for you to discuss
aspects of the students safety in the workplace.
Additional Information for Employers is available at: https://www.det.nsw.edu.au/vetinschools/worklearn/
worklearnpolicy.html or scan the QR code opposite.
Signature of host employer/workplace supervisor

Date

Print name

Position

Privacy notice-for all parties

The information provided by students, parents/carers and host employers is obtained for the purpose of coordinating a workplace learning
opportunity for the school student. The NSW Department of Education and Communities will use the information to meet student health, duty of
care and protection responsibilities and to support the information needs of the student, host employer and the parent/carer. The Work Placement
Service Provider might access information related to HSC VET work placements but only with the approval of the Principal.
Providing this information is voluntary. However, if you do not provide any of the information requested then the student may not be able to
undertake the planned workplace learning.
The information you provide will be stored securely and kept for a minimum of two years where there is no further action relating to the placement.
The information will only be disclosed for purposes directly related to the purpose for which it is collected.
You may correct any personal information by contacting the teacher in charge of the students workplace learning program at the students school.

Page 3 of 4

Student Placement Record 2014

Students Name:

School: Newtown H.S. of the Performing Arts Host Business:

Section 4: Parent/carer permission (Must be completed for students aged under 18 years)
Name

Relation to student

Address

Mobile

Work Phone

Home Phone

Medicare no.

Post code

Contact phone number after normal business hours

I have read The Workplace Learning Guide for Parents and Carers and understand my role and responsibilities.
I will immediately notify the school if I have any concerns and the school will follow up and action.
I am aware of the contents of the Privacy Notice on Page 3.
Tick if the placement includes out of normal business hours e.g. 6-9pm.
If ticked, please respond to either 1 or 2 below:

1.

Years 11-12: where relevant:

I agree to make myself available as a contact for my child after normal business hours in the event of an

emergency OR I nominate

on telephone

to be the willing and reliable contact out of normal

business hours.
Their relationship to my child is

2.

and they have accepted these responsibilities.

Years 9-10: contact arrangements must be negotiated with the Principal by the parent/carer and student. The arrangements are:

 y child has the following medication, medical condition, (e.g. severe asthma,
M
type 1 diabetes, epilepsy, anaphylaxis or other severe allergy) disability or
learning and support need that may affect their safety during the placement.

or

N/A

If so what support or adjustment do you think your child will need to make their placement successful?
If more space is needed, please attach the information.
I understand that if my child is diagnosed as being at risk of anaphylaxis, I will provide an adrenaline auto-injector for my child for
the placement.
My child has a ASCIA Action Plan or individual health care plan

YES

NO

If Yes, I consent to a copy being provided by the school to the

host employer e.g. health care plan cover sheet

YES

NO

Tick if the placement choice includes overnight accommodation away from home. I understand this will need special approval and additional
documentation.

I consent to my child in Year

Signature of parent/carer

undertaking the placement outlined on this Student Placement Record.

Years 11-12: signature/date of adult approved by the
parent to be the after normal business hours contact

Date

Section 5: School approval of the placement

The student has been prepared for the workplace by the school to optimise the students safety and achievement during their placement.
The placement is supported according to the Departments Workplace Learning Policy and Associated Documents and Forms.
The school will report incidents affecting the safety of students, including near misses, while undertaking workplace learning in accordance with
the Departments Incident Reporting Policy and Procedures. In accordance with the Policy, incidents must be reported as soon as possible but
within 24 hours.
The student has been issued with a personal Student Safety and Emergency Contact Card and trained how to use it.
If medical information, support or adjustments are to be provided this has been shared with the host employer. If the student is diagnosed as
being at risk of anaphylaxis, the school has confirmed that the parent or carer has provided an adrenaline auto-injector for their child for the placement.
The School has provided a copy of the students ASCIA Action Plan or health care plan cover sheet to the host employer and has discussed it
with them.
Tick:
N/A or
YES
NO
Where the placement involves accommodation away from home, relevant documentation is completed and attached.
Where the employer has asked to be contacted, the employer has/has not been contacted by phone/visit. See last tick box on page 3.
I am satisfied that all of the above have been completed and that all parts of this Student Placement Record are complete and signed as required
and that the placement is suitable for this student.
Signature of Principal/nominee

Date

Print name

Careers
Position
in SchoolAdviser

Page 4 of 4

Student Placement Record 2014