Placement Agency Health & Safety and Insurance Verification – Mohawk College Allied Health and Medical Imaging Programs

This form must be completed by the Agency Supervisor (e.g. Mentor, Clinical Supervisor, Clinical Education Leader, or Preceptor) in collaboration with the student by the end of the 1st day of placement in order to meet health, safety, insurance, and liability requirements of the placement.

If you are hosting more than 5 students please use this PDF form and email it to AlliedHealthFPS [at] MohawkCollege.ca (AlliedHealthFPS[at]MohawkCollege[dot]ca). 

Placement Agency Health and Safety Multiple Students

 

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?

Supervisor/Mentor

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

XXX-XXX-XXXX
.

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?

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 and Universities (MCU). Students attending placement at a Placement Agency that already has WSIB coverage will be covered by the MCU's WSIB policy. If the assigned agency does not have its own WSIB coverage, then the student will be covered under the MCU's CHUBB policy.

The Field Placement Agency 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 Agency’s workplace.

In the event of injury/disease while on placement the student is required to immediately report the accident/injury to the Placement Agency and it must be reported to the relevant Field Placement Specialist within 24 hours. The Placement Agency 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 Agency, the student, and the Mohawk College representative. Where the Field Placement Agency is covered under WSIB they must complete a Letter of Authorization to Represent the Field Placement Agency. This allows Mohawk College to represent the Field Placement Agency 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.

Health and Safety

This form is general to all of our programs, so there may be items that are not relevant to a specific program or location. These can be marked as N/A.  If the employer has a more robust OHS awareness system for students, please share with your Field Placement Specialist, as this would need to be evaluated and documented by our team.

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, or code blue cart, readily available and well-stocked and the student(s) is aware of its location
Student(s) and preceptor 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

Optional: 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.

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.