Student Name: _____________________________ Cell #: _______________________

Student Signature: __________________________ Date: _______Sept 27, 2023_________________

Business Name: ____________________________ Supervisor: ______________________

Email: ____________________________________ Phone: ________________________

Address: ________________________________________________________________________________

Worksafe BC (WCB #):________________ Employer Onsite Orientation Provided: YES • NO •

(see reverse side for orientation)

A workplace agreement must be in place prior to the student commencing the placement. The student agrees to be
under the direct supervision of the Worksite Employer. The Worksite Employer will provide worksite & specific safety
training. The Worksite Employer agrees to allow the teacher to have access to the worksite.

For PAID placements, students are covered under the employers WCB. For UNPAID placements, students are covered
under the Work Experience Education Program Placement Agreement (from myWEX).

Student Job Title:____________________________

General Description of what you will be doing on your work experience placement:

Please Check ( √ ) the Employability Skills that you practice during your placement.
Communication Positive Attitude Working with others
Information Management Responsibility Organization & Planning
Willingness to Learn Adaptability Problem Solving
Workplace Safety Time Management Other: _____________________

Work Schedule
Give an example of your typical work week: Dates of employment:
(List Hours)
Sun Mon Tues Wed Thurs Fri Sat
Employer/Trainer and Student Safety Checklist
Complete the safety training checklist for all points that are relevant to the worksite by adding a check mark beside those items in
which the worker received training. Return this page signed to your teacher.

Completed
Rights and Responsibilities

1. General duties of employers, workers, and supervisors

2. Workers right to refuse unsafe work and procedure for doing so

3. Workers responsibility to report hazards and procedure for doing so

Hazard Recognition & Injury Prevention

1. Identify hazards on the job site and how to deal with them

2. Personal Protective Equipment (PPE) – what to use, when to use it, and where to find it

Incident & Accident Response Procedures

1. Procedure for identifying incidents of workplace bullying or harassment
2. Identify fire exits, extinguishers, alarms, first aid kits, eye wash and meeting point

3. Name and contact information of first aid attendants

4. Procedures for responding to an accident and/or emergency

Hazardous materials and WHMIS

1. Discuss what hazardous materials are in the workplace

2. Location of Materials Safety Data Sheet (if applicable)

3. Procedures for an emergency involving hazardous materials, including clean-up of spills

Work Placements follow the local, regional, and provincial health orders. Third party organizations may require students to show
that they are fully vaccinated to participate, or require that masks be worn.

Student Parent/Guardian Teacher Employer/Supervisor

Name: Name: Name: Name:
____________________ ____________________ John Mcparland ____________________
Signature: Signature: Signature: Signature:
____________________ ____________________ John McParland ____________________