Employer Health & Safety Check

This form must be completed by the Agency Supervisor or the Student's Mentor in collaboration with the student by the end of the 1st day of placement.

If you are uncomfortable completing an on-line form or you need to fill out the form for multiple students, you can request a fillable PDF form. Please send a request to kim.beaul [at] mohawkcollege.ca (kim[dot]beaul[at]mohawkcollege[dot]ca)

 

You must use either a laptop or desktop computer not a mobile device or phone.

Student Information

Please complete one form for each student

usually firstname.lastname@mohawkcollege.ca

Agency Information

Including department/program name if applicable
Where will the student be doing their placement?
What Mohawk Program is the student in?

If the student is in a program other than the ones listed here you have been give the wrong form link.  If this is for an Allied Health program please use this form: https://www.mohawkcollege.ca/form/employerhealthsafety-alliedhealt

 

Supervisor/Mentor

Who will be directly supervising the student and be responsible for attendance verification & evaluations?

XXX-XXX-XXXX
.
Please include contact information when available

Field Placement Details

In what semester(s) will the student be doing this field placement?
Please make sure this is reflected in the start/end dates
Is the student required to complete an Orientation before they start their placement?
Required: yyyy-mm-dd
Required: yyyy-mm-dd
Days of Placement
The above dates and times have been discussed with the student

Health and Safety

Yes No Not Applicable
Student(s) has been provided with appropriate onsite supervision, name and contact information for Placement Supervisor
Student(s) is aware of their right to refuse unsafe work
Student(s) provided with information and location of workplace’s specific procedures on, but not limited to: Health and Safety, Workplace Harassment, Workplace Violence
Student(s) trained on safe work procedures and operation of equipment relevant to their placement
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
Student(s) informed of any restricted or prohibited areas, tools, equipment and machinery in their immediate work area
Student(s) informed of hazards in the workplace that may affect the student, how they are controlled, and how to navigate them
Student(s) informed of process for reporting safety concerns
Student(s) informed of what to do in the event of a fire or other emergency (e.g. evacuation procedures)
Student(s) informed of location of fire exits and fire extinguishers
Confirm there is a first aid kit readily available and well-stocked and the student(s) is aware of its location
Student(s) and supervisor(s) discussed procedures for reporting accidents and injuries and how to obtain first aid or medical attention
Student(s) informed of Workplace Hazardous Materials Information System (WHMIS) and location of Material Safety Data Sheets/Safety Data Sheets

Police Clearance

The Field Placement Site (aka Field Placement Employer) is responsible for verifying the validity of the Police Clearance/Vulnerable Sector Check (VSC). Please complete the following information regarding who has verified this student's Police Clearance.

The student is required to have a valid Police Clearance

Student Insurance

As a student completing an unpaid work placement they are covered under either the Workplace Safety and Insurance Board (WSIB) or private insurance  coverage (CHUBB) both are provided by the Ministry of Colleges and Universities (MCU), depending on the Placement Employer’s coverage.  If the assigned agency is not covered under WSIB the student will be covered under the Ministry's CHUBB policy, otherwise, they will be covered by the Ministry's WSIB policy.

The Field 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 Field 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. 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, they must also 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 Field Placement Employer is covered under WSIB they must complete a Letter of Authorization to Represent the Field Placement Employer. This allows Mohawk College to represent the Field Placement Employer on matters related to the WSIB claim.  The Mohawk College representative 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.

Our Organization is covered by WSIB
Is there anything you want to note about this particular placement?

This form must be approved by a placement Supervisor/Mentor.

Must be completed in collaboration with the placement Supervisor/Mentor.

If  you are not sent to a Thank You screen after you have clicked Submit it means that you missed a required field. Please double check to make sure that all required fields have been completed. A copy of this completed form will be sent to the student, the agency, and the registering college. A copy should be retained until the end of the field placement.