Uncontrolled copy. Refer to the Department of Education and Training Policy and Procedure Register at
http://ppr.det.qld.gov.au to ensure you have the most current version of this document.
Privacy Statement
The Department of Education and Training (’the Department’) is collecting personal information on this form in order to make a work experience
arrangement for a student under the Education (Work Experience) Act 1996. The personal information will only be used by authorised
employees within the student’s school, the Department, and the nominated work experience provider for the purpose of organising and
implementing the arrangement. The information may also be given to the Queensland Government Insurance Fund and WorkCover Queensland
for the purpose of managing insurance coverage as required by the Education (Work Experience) Act 1996 (Qld). Your information will not be
given to any other person or agency unless you have given us permission or we are required by law to do so.
This agreement establishes a work experience arrangement under the Education (Work Experience) Act 1996, and should be completed and
signed, where indicated by the student, their parent, the work experience provider and Principal of the student’s school.
School name:
A
N
D
Provider’s
name:
School address:
Provider’s
address:
Work Experience
Coordinator:
Nominated
Supervisor:
Phone:
Phone:
Email:
Email:
PLACEMENT DETAILS
Industry/
Occupation:
Model of work experience:
(Select one)
Work sampling
Structured work placement
Dates of
placement:
Number of
days:
Hours of
work:
Summary of proposed student workplace activities (list main activities):
Special requirements for placement (e.g. uniform, personal protective clothing/equipment):
STUDENT DETAILS
Student name:
Date of birth:
/ /
Gender:
Male
Female
Phone:
Email:
Emergency
contact:
Out of school hours
emergency phone:
Work experience placements
for school students
Agreement
Uncontrolled copy. Refer to the Department of Education and Training Policy and Procedure Register at
http://ppr.det.qld.gov.au to ensure you have the most current version of this document.
Medical information:
(List any pre-existing medical conditions that may
impact on the student’s work experience placement.
Please attach details of medications and health plans
where relevant.)
STUDENT RESPONSIBILITIES
I understand that my conditions of placement include:
attendance at my placement for the full work experience period
immediately notifying my school and the work experience provider if I am unable to attend or am late
demonstrating behaviour aligned to my school’s responsible behaviour expectations and in keeping with the accepted
standards of my work experience provider
performing my duties to the best of my ability and complying with all reasonable directions given by the work experience
provider
following all workplace health and safety procedures in my workplace
notifying my school and work experience provider of any incident or accident in the workplace which may involve me.
Student
signature:
Date:
/ /
PARENT CONSENT (Applicable to students under 18 years of age)
I understand that my responsibilities relating to my student’s work experience placement include:
providing any information about medical conditions and/or medication relating to my child which may impact on the safety of
my child or the safety of others in the workplace
organising transportation for my child to and from the work experience placement location
notifying the school and work experience provider if my child is unable to attend or is late.
I consent to participating in work experience as stated.
Parent
signature:
Date:
/ /
WORK EXPERIENCE PROVIDER’S AGREEMENT
I enter into an arrangement for the named student to be placed with me for the purpose of work experience. Conditions of
placement include:
understanding my responsibilities relating to health and safety under the Work Health and Safety Act 2011 (Qld)
informing the student of particular safety requirements of this workplace including personal protective clothing/equipment
notifying the school/work experience provider of any unexplained absences by the student
notifying the school/work experience provider of any incident or accident involving a school student, any action undertaken
and damages to property involving the student during this placement
providing supervision for the student at all times
ensuring the hours worked by the student do not exceed the normal hours worked in my industry
ensuring the student will not perform work which is prohibited by law or is unsuitable for a student placed in a work
experience environment
understanding that the arrangement may be terminated at any time by either the school principal or myself
ensuring the student is not paid whilst undertaking work experience
understanding the level of liability cover provided by the Department of Education and Training.
Work Experience Provider’s
signature:
Date:
/ /
PRINCIPAL’S AGREEMENT
I enter into an arrangement for the named student to be placed for the purpose of work experience with the above named work
experience provider.
Principal’s
signature:
Date:
/ /
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