Year 12 Work Experience: Employer Declaration, Safeguarding and Health and Safety
Thank you very much for agreeing to support our Year 12 student with their work experience placement. For our records, can you please complete this employer information for the Work Experience placement.

If you have any questions about completing this form, please contact Kelly Sharpe, Debden Park High School Sixth Form Administrator on kelly.sharpe@debden-tkat.org.
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Email *
Name of student
Work experience lead contact name
Name of work experience company
Address
Telephone Number 
Do you have Employers’ Liability Insurance

We regret that only those Employers with Employer Liability cover are eligible for pupils at DPHS to take Work Experience.

 *
Employers' Liability Insurance policy number 
Name of insurance company for Employers' Liability Insurance
Employers Liability Insurance renewal date 
Are there suitable facilities facilities for a pupil of school age ? 
Clear selection
Hours of work including lunch hour 
Is there a current health and safety policy?
Clear selection
Will a workplace and health and safety induction be provided ? 
Clear selection
Are there adequate arrangements for First aid?
Clear selection
Protective clothing (PPE) provided ? 
Clear selection
If yes please specify 
Is PAT testing up to date ?
Clear selection
Are aspects of the work unsuitable for students with a health problem (eg, Asthma, allergies, etc..)
Clear selection
Type of risk associated with this placement
Clear selection
Please confirm you have carried out a young persons risk assessment taking into account students inexperience and immaturity (mandatory if placement is high risk) 
Clear selection
Name and position of person responsible for organising the continuous competent supervision and protection of the student ensuring that appropriate induction and training will be provided.  

We are required by the Department of Education to keep children safe during work experience.  As a statutory guidance for schools and colleges we are required to request that whilst students are on placement they are supervised by more than one person and that they are Not barred from working with children.

                                                                   

Can you please list the names of your staff who will be supervising.

As part of our safeguarding checks please confirm that you have read and understood the requirements of the attached Safeguarding Statement of Principles sheet. Please provide name and position.

 *
Subject to an acceptance visit by an Employer Consultant, please confirm that you have agreed this placement with the student, by signing below with your name and company position.
*
A copy of your responses will be emailed to the address you provided.
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