• Company name

  • Nature of business

  • Business address
  • Tel no.

  • Email address

  • Contact name

  • Position

  • Name of student

  • Employer/public liability insurance.
    Please enter details below or email a copy to xxxxxxx@leedscitycollege.ac.uk

  • Insurer name

  • Policy number

  • Expiry date

  • Health and Safety policy

  • Do you have a health and safety policy

  • Is there a clear commitment to health, safety and welfare?

  • Induction

  • Will the provider complete an introduction into the workplace ?
    This should include:
    - Going through the risk assessment for the workplace. If it is not written down, identifying the hazards of the environment.
    - Accident and emergency procedures.
    - Any machinery which is to be used and the appropriate training.
    - How young people are considered in the arrangements and the additional controls if relevant.

  • Does the employer provide ongoing health and safety information and training?

  • Supervision/Safeguarding

  • Name of identified Supervisor or person with overall responsibility of the learner:

  • Will the employer contact the college if you have any concerns over the learner or if the learner is injured during the placement

  • Emergency arrangements

  • Are there arrangements in place for emergency situations such as fire?

  • First Aid

  • What are your procedures if first aid is required?

  • Do you have first aid supplies that can be accessed in an emergency?

  • Safe and healthy working environment

  • Are the premises ( structure, fabric, fixtures and fittings) safe and suitably maintained?

  • Is work equipment adequate and all safety controls (guards etc) in place and are appropriately maintained?

  • Personal Protective Equipment (PPE) (If applicable)

  • Is the required clothing/equipment supplied (e.g. Gloves,apron)

  • How will the learner be trained in the use of PPE (if applicable)

  • Equality and Diversity

  • Leeds City college fully comply with the Equality act 2010. Can you confirm that you comply with this legislation?

  • If you have any questions or want to see a copy of our Equality and Diversity policy then please add this to the comment section.

  • Welfare Facilities

  • Do you have the following?
    -Toilets
    - Somewhere to wash hands with warm water and somewhere to heat food
    -Rest facilities

  • Health

  • Are there any health risks associated with the workplace that would make it unsuitable for students with particular medical conditions? If yes, please comment:

  • Are there any action points that need addressing before a young person can be placed? If yes please add details below.

  • Action required
  • Employer Declaration

  • I confirm that the information given in this questionnaire is correct. I understand my responsibility for the health, safety and welfare of the learner under the Health and Safety at Work Act 74. I will not permit them to exceed 39 hours of work, undertake work prohibited by law, or deemed to be too hazardous for the young and inexperienced. I am aware of the responsibility with regards to the protection and safeguarding of young people on work premises and agree to provide a full induction at the start of placement and provide suitable supervision at all times.

  • I agree that for the purposes of audit and work related learning the information on this from may be passed to a third party. Employers name:

  • In my opinion the Health and Safety for the placement is suitable for a learner. A review should be carried out on or before:

  • Date:

  • Approved

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