Information
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Student name
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Placement details
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Placement address
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Main activities of placement
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Dates when placement is being completed
Pre placement information:
Responsibilities of all parties.
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Does this type of placement require the student to have DBS clearance?
Tap to enter information
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Include details of who has checked the DBS forms and confirm that the placement has accepted these details:
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Student responsibilities:
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Student contact details (include name, phone number and email address)
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Emergency contact details (include name, relationship with student and contact number):
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Do you have any medical conditions or allergies that may need reasonable adjustments whilst at placement? (If YES, tap on the question box and type in details)
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Student signature
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Employer/placement responsibilities:
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Employer contact details (include name, phone number and email address)
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Employer signature
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College responsibilities:
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College contact details (include name, phone number and email address)
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College signature
Placement Health & Safety information:
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This section is used to record information relating to health & safety at the work placement
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Is there a current employers liability insurance certificate available?
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Enter insurance details here:
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Is there a named person , responsible for supervising the learner?
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Enter the details of the supervisor here:
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General safety topics. Which of the following are evident in the work place:
- fire fighting equipment
- fire alarms
- health & safety law poster
- health & safety signs
- welfare facilities (toilets, washroom, canteen area etc)
- procedures for dealing with emergencies
- first aid boxes/provision
- supply of PPE
- risk assessment
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Did you recieve a workplace induction?
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What subjects did the induction cover?
Record of placement activities undertaken:
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The following sections should be used to record details of activities undertaken on placement. Include dates and a brief description.
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Week 1 - commencing.......
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Week 2 - commencing.......
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Week 3 - commencing.......
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Week 4 - commencing.......
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Week 5 - commencing.......
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Week 6 - commencing.......
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Week 7 - commencing.......
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Week 8 - commencing.......
Work placement assessment criteria:
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This section should be used to provide evidence relating to the subjects listed below.
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Start/finish times known and adhered to?
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Student had good attendance and punctuality?
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Student recieved a workplace induction and was able to follow guidelines ( give examples if possible)
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Student dressed appropriately throughout placement times?
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Student was able to recieve and follow instruction?
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Student was able to check their own understanding of instructions and was happy to ask for clarification?
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Student was able to carry out activities independently ( list examples where possible)?
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Student was able to communicate with colleagues and customers in an appropriate manner (list examples where possible)?
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Student could accept positive and negative feedback and understand the reasons behind the feedback?
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Student was motivated towards the work placement and activities?
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Student was able to complete tasks in given time scales?
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Student was able to pass on information to others in an appropriate manner?
Review of work placement experience by student:
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What do you feel were your key strengths when carrying out your work tasks?
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Is there anything you feel that you could improve on?
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What aspects of the placement did you enjoy the most?
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What health & safety rules did you have to follow?
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Has the placement confirmed to you that this industry is the correct choice for you?
Employer feedback:
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What strengths did the student display whilst with you?
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Did the student show a motivated response to working in the industry?
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What advice would you give to the student to assist them in moving into full time employment?
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Any other comments:
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Signed on behalf of the placement:
