Health and Safety Declaration Form

Current Declaration of Understanding: Workplace Insurance
Complete

Student's Name:

Student's Program:

Placement Employer (Company) Name:

Process for Workplace Insurance Claims for Postsecondary Students on Unpaid Work Placements

STUDENT INSURANCE: The government of Ontario, through the Ministry of Colleges & Universities (MCU), reimburses the Workplace Safety & Insurance Board (WSIB) for the cost of benefits it pays to Student Trainees enrolled in an approved program at a Training Agency (Mohawk College). Ontario students are eligible for WSIB coverage while on unpaid work placements that are required by their program of study, if the placement agency is covered by WSIB (mandatory or by voluntary application coverage).

The MCU also provides private insurance coverage through CHUBB to students should the unpaid placement required by their program of study take place with an agency who is not covered under the Workplace Safety and Insurance Act, and limited coverage where placements take place outside of Ontario or Canada. Students are advised to obtain additional insurance coverage as Chubb does not provide full compensation or coverage during non-work placement hours.

Please be advised that Mohawk College is required to disclose personal information to the Placement Agency relevant to the placement, limited to your full name, local address, telephone number and placement schedule. Personal information may also be disclosed to the MCU as related to the administration of a WSIB or CHUBB workplace insurance claim.

Declaration

I have read and understand that WSIB or private insurance coverage will be provided through the Ministry of Colleges & Universities while I am on an unpaid work placement as arranged by Mohawk College as a requirement of my program of study. I understand that all accidents, injuries or illnesses sustained while participating in the unpaid work placement must be immediately reported to the Placement Agency and to my Mohawk College Placement Coordinator. A Postsecondary Student Unpaid Work Placement Workplace Insurance Claim form must also be completed in the event an insurance claim for an injury, illness or disease is submitted to the WSIB or CHUBB Insurance.

I acknowledge that I fully understand the nature and terms of this agreement. I understand that I have the right to obtain independent legal advice with respect to this agreement if I wish. I confirm that I am signing this agreement voluntarily and without duress.

https://www.ontario.ca/page/workplace-insurance-college-and-university-students-unpaid-work-placements

I have read, understand and agree to the above Terms & Conditions

yes

Employer's Information

Name:

Title:

Employer's Email:

You will receive a copy of this completed form sent to the email address provided.

Student's Email:

The student will receive a copy of this completed form sent to the email address provided.

Health & Safety Checklist

Please record which of the following health & safety topics you have discussed with the student.

Questions	Yes	No	Not Applicable
Supervisor Contact Information Student(s) has been provided with appropriate onsite supervision, name and contact information for Placement Supervisor	Yes	No	Not Applicable
Unsafe Work Student(s) is aware of their right to refuse unsafe work	Yes	No	Not Applicable
Workplace Procedures Student(s) provided with information and location of workplace’s specific procedures on, but not limited to: Health and Safety, Workplace Harassment, Workplace Violence	Yes	No	Not Applicable
Safe Work Procedures Student(s) trained on safe work procedures and operation of equipment relevant to their placement	Yes	No	Not Applicable
Personal Protective Equipment Student(s) trained in proper use of relevant Personal Protective Equipment (PPE). (E.g. respirator, gloves, eye/face protection, footwear, etc...) by either the college or the placement location	Yes	No	Not Applicable
Restrictions in Workplace Student(s) informed of any restricted or prohibited areas, tools, equipment and machinery in their immediate work area	Yes	No	Not Applicable
Hazards in Workplace Student(s) informed of hazards in the workplace that may affect the student, how they are controlled, and how to navigate them	Yes	No	Not Applicable
Reporting Safety Concerns Student(s) informed of process for reporting safety concerns	Yes	No	Not Applicable
Emergency Procedures Student(s) informed of what to do in the event of a fire or other emergency (e.g. evacuation procedures)	Yes	No	Not Applicable
Fire Exits/Fire Extinguishers Student(s) informed of location of fire exits and fire extinguishers	Yes	No	Not Applicable
First Aid Kit Confirm there is a first aid kit readily available and well-stocked and the student(s) is aware of its location	Yes	No	Not Applicable
First Aid Attention Student(s) and preceptor discussed procedures for reporting accidents and injuries and how to obtain first aid or medical attention	Yes	No	Not Applicable
WHMIS Student(s) informed of Workplace Hazardous Materials Information System (WHMIS) and location of Material Safety Data Sheets/Safety Data Sheets	Yes	No	Not Applicable

Date Completed

Health and Safety Declaration Form

The following form must be reviewed and completed by the the Student's Field Placement Supervisor, in collaboration with the student.

Process for Workplace Insurance Claims for Postsecondary Students on Unpaid Work Placements

Employer's Information

Health & Safety Checklist

Find information for...

Future Students

Current Students

Indigenous Students

International Students

Alumni

Industry and Employers

Parents and Caregivers

Athletes ⤻

Educators

Donors and Supporters

Community

Media

Careers at Mohawk

Employees

Mohawk College