Health and Safety Declaration Form

Current Declaration of Understanding: Workplace Insurance
Complete

Student Information

Student's First Name

Student's Last Name

Student's Email:

StudentID

Placement Employer

Placement Employer (Company) Name:

Address (#, Street, City)

Supervisor/Mentor

Name:

Title:

Employer's Email:

Field Placement Details

Student's Program:

What Mohawk Program is this student enrolled in?

Advertising & Marketing Communications Management

Bachelor of Analytics and Data Management

BBA Trades

Broadcasting

Digital Health

Graphic Design

Office Administration - Health Services

Power Engineering

What Semester will this placement be in?

Fall

Winter

Spring/Summer

Start Date of Placement

End Date of Placement

Student Insurance

Students completing an unpaid work placement are covered under either the Workplace Safety and Insurance Board (WSIB) or private insurance coverage (CHUBB). Both options are provided by the Ministry of Colleges, Universities, Research Excellence and Security (hereby called the “Ministry”). Students attending placement at a Placement Employer that already has WSIB coverage will be covered by the Ministry’s WSIB policy. If the assigned agency does not have its own WSIB coverage, then the student will be covered under the Ministry’s CHUBB policy.

The Placement Employer agrees that it will provide the Student Trainee with health and safety training and supervision to protect them from health and safety hazards that may be encountered at the Placement Employer’s workplace.

In the event of injury/disease while on placement the student is required to immediately report the accident/injury to the Placement Employer and it must be reported to the relevant Mohawk College Placement Specialist within 24 hours. The Placement Employer must complete an accident report and provide a copy to the Mohawk College representative.

If a workplace insurance claim is reportable to the WSIB or CHUBB, the Placement Employer must complete a Postsecondary Student Unpaid Work Placement Workplace Insurance Claim Form, which requires signatures from the Placement Employer, the student, and the Mohawk College representative. Where the Placement Employer is covered under WSIB they must complete a Letter of Authorization. This allows Mohawk College to represent the Placement Employer on matters related to the WSIB claim. The Mohawk College representative will coordinate this process.

For more information regarding this process visit: https://www.ontario.ca/page/workplace-insurance-college-and-university-students-unpaid-work-placements

The student has signed a Student Confirmation Form to acknowledge that they understand this process.

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

yes

Health & Safety Checklist

If the student has completed an organization-provided (internal) health and safety training, please select yes. (Review the list below as a guide.) If the student has not completed an internal health and safety checklist, please complete the below chart.

Yes

Please record which of the following health & safety topics you have discussed with the student. This form is general to all of our programs, there may be items that are not relevant to a specific program or location. These can be marked as N/A.

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

Comments

Please note any additional information that you would like to share with the Field Placement Specialist about this placement

This form must be approved by a placement Supervisor/Mentor

Approved By

Title

Email Address

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. Both the student and the supervisor will receive a copy of this form for their records.

Student Information

Placement Employer

Supervisor/Mentor

Field Placement Details

Student Insurance

Health & Safety Checklist

Comments

This form must be approved by a placement Supervisor/Mentor

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