Work Experience Health & Safety Form

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Work Experience Health and Safety Form

Name of the person at Barlows you have been dealing with over your work experience application.(Required)

Student details

Name(Required)

First Last

Student phone numer(Required)

Home Address(Required)

Street Address Address Line 2 Area City/Town Post Code

Date of Bith(Required)

DD slash MM slash YYYY

Year Group(Required)

Parent/Carers Name(Required)

Relationship to Student(Required)

Parent/Carers phone number(Required)

Parent/Carers email address(Required)

School Details

School Name(Required)

School Address(Required)

Main School Contact Name(Required)

Main School Contact Telephone Number/School Telephone Number(Required)

Main School Contact Email Address(Required)

Placement Details

Requested start date(Required)

DD slash MM slash YYYY

Requested end date(Required)

DD slash MM slash YYYY

Requested working days(Required)

Requested working hours(Required)

Dress code – all must be agreed to(Required)

Select exactly 4 choices.

Smart Casual – no sportswear, headwear or fashion clothing.

Practical footwear – Safety footwear (if instructed) no trainers or high heals

Hair tied back – no long hair

Outdoor coat – casual waterproof outdoor coat – no sports or fashion items

Any additional requirements or information will be provided prior to your start date

Health and Safety Information

Barlows UK Ltd have a duty of care under The Health & Safety at Work Act 1974 to ensure so far as is reasonably practicable, the health, safety and welfare at work of all his employees and others in its control. Work placements must follow the information provided and must ensure that they act safely and sensibly at all times and follow instruction. Work placements are to observe and may be required to assist a competent person in their duties by passing items that will cause no harm or injury or holding items within their capability. Placements may be requested to other duties within their capability. Requests of the competent person must always be followed. Any concerns can be reported to the persons named in employee details. Any health and safety breach will treated very seriously and the placement will be terminated immediately. Below is a risk assessment to assess the risks a placement may be exposed to. The placement in this situation is refered to as the young person.

Risk Assessment – tick each one to mark as read and understood.

Young Person(Required)

The young person will be supervised at all times by the competent person.

Maturity(Required)

The competent person will continuously monitor the young persons attitude to work and the works area. Fooling around is not acceptable and could result in incident and will resolve in being removed from the placement.

Experience(Required)

The competent person will instruct the young person on what is required. The competent person understands that the young person will have little or no experience in the task being carried out.

Awareness(Required)

The competent person will inform the young person that they need to ensure they are always aware of their surroundings including vehicles, tasks, objects and other workers. This will be monitored by the competent person. The young person has a duty to ensure they act safely and sensibly at all times and are aware of their surroundings at all times.

Location(Required)

The young person will not be taken into a location that may be dangerous or have the potential to become dangerous under a fault condition.

Others(Required)

The young person is to be aware of others in the working area and will not be left alone with anyone under the age of 18 or anyone unknown to the company.

Tools & equipment(Required)

The young person will observe the works and not use any tools or equipment. The young person may assist the competent person by passing or holding tools as required for the task being carried out.

Manual Handling(Required)

The young person will not be expected to carry or hold any thing that exceeds 1kg.

Slips, Trips and Falls(Required)

The competent person will ensure that any trip hazards are identified to the young person. The young person has a responsibility to always be aware of their surroundings and act safely and sensibly at all times.

Working at height or working below ground level(Required)

The young person will not carry out any works at height off steps or ladders. The young person will not carry out any works below ground level. The young person will only work at ground level on no access equipment.

Dust(Required)

The young person will not be expected to enter or work in a dusty environment. The competent person will make a judgement on the works and may ask the young person to wait in a safe area whilst the task is carried out.

Noise(Required)

The young person will not be expected to enter or work in a noisy environment. The competent person will make a judgement on the works and may ask the young person to wait in a safe area whilst the task is carried out.

Falling Objects(Required)

The young person will not be expected to enter or work in an environment where items may fall from height. The competent person will make a judgement on the works and may ask the young person to wait in a safe area whilst the task is carried out.

Confined Spaces(Required)

The young person will not be expected to enter or work in an environment where escape in an emergency may be restricted. The competent person will make a judgement on the works and may ask the young person to wait in a safe area whilst the task is carried out.

Control of Substances Hazardous to Health(Required)

The young person will not be expected to enter or work in an environment where Control of Substances may become a Hazardous to Health. The competent person will make a judgement on the works and may ask the young person to wait in a safe area whilst the task is carried out.

Mobile Phones/Tablets(Required)

The young person will not be able to use their mobile phone or wearable equipemnt whilst in the work place. The young person will be given time when on breaks to access their phone if required. If an urgent call is to be taken the competent person must allow this and escort the young person to a safe location to take the call . Mobile phones and wearable tech can be a distraction to the user and others.

Photography(Required)

The young person will under no circumstances take photos of anything related to the placement or Barlows UK Ltd with out permission from Nigel Johnson – 07740596048. Any photos taken without permission or shared on social media platforms will result in the placement being terminated and further action being taken.

Personal Protective Equipment(Required)

Work specific personal protective equipment will be issued as required.

Agreements – to be completed by the student

Do you have any health conditions the employer needs to be aware of?(Required)

Yes

If Yes, please detail below

Do you have any physical conditions we need to be aware of?(Required)

Yes

If Yes, please detail below

Do you have any special requirements we need to be aware of?(Required)

Yes

If Yes, please detail below

Student Disclaimer

As the student named in this form, I agree to take part in this work experience programme. I also agree to hold in confidence any information about the employer’s business which I may obtain during this work period and not to disclose such information to any other person without the Employer’s permission. I also agree to observe all safety, security and other regulations laid down by the Employer and made known to me either by the Employer’s representative or by the displayed instructions. I will pass on to my parent or guardian any information, given to me by my employer, which may affect my personal health, safety or welfare.

I confirm that(Required)

To the best of my knowledge and belief, the information provided is correct

I have read and understood this form, any concerns have been raised with the School and Employer.

Students Signature(Required)

Date(Required)

DD slash MM slash YYYY

Parent/Carer with legal responsibility for the student Disclaimer

As parent / carer of the student named above I confirm that I have read and understood the information on this form. I agree to his/her taking part in the work experience and that he/she will observe the conditions set out above. I confirm that he/she does not suffer from any medical or other condition which could result in unnecessary risk to his/her health or safety or to the safety of another person.I confirm that if he/she leaves the employer’s premises during lunch or break periods, no liability can be accepted by the employer or the school for any incident that may occur. Once on the placement, parents should discuss the arrangements for lunch and break periods with their child and make sure they are suitable. I consent to photos being taken for promotional purposes only.

Parent/Carer Name(Required)

First Last

Parent/Carer Signature(Required)

Date(Required)

DD slash MM slash YYYY

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Employer Agreement – The person named below as representative of Barlows UK Ltd, I agree to the student named above working at Barlows UK Ltd, and to abide by all legislation relating to Equal Opportunities, Health and Safety and Child Protection. Barlows UK Ltd Employer’s Liability Insurance is attached to this document to provide cover against accident and injury caused to the student by negligence of the employer or another employee and will accept or insure myself against liability for loss, damage or injury caused by the student in the same way as for other paid employees. Barlows UK Ltd has prepared this Health & Safety document to detail information relevant to the students placement. The person named below takes responsibilty of the student whilst working at Barlows UK Ltd and is to ensure that all information available relevant to the placement is communicated. The student will only work with over 18 year olds that hold a DBS check no more than 3 years old from date of placement.

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Managers Name responsible for student

First Last

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Signature

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Date

DD slash MM slash YYYY

Work Experience Health & Safety Form