Section D. Structured Workplace Learning Forms

Transcription

1 Section D Structured Workplace Learning Forms

2 Section D: Contents Relevant Structured Workplace Learning Forms All relevant Forms and supporting materials are available on the DEECD website located at: The following Structured Workplace Learning Forms are available in this section: 1 Victorian Ministerial Order No 55 forms a Structured Workplace Learning Arrangement Form b Structured Workplace Learning Guidelines for Employers 2 Information for Employers guidelines and brochure 3 Information for parents brochure 4 WorkCover sample forms 5 Sample Record of Contact Form for teachers making contact with students on structured workplace learning placements 6 Arrangement form for students who require accommodation away from home (within Victoria) 7 Interstate Arrangement Forms (Refer to section C for more details on interstate arrangements) a. South Australian Workplace Learning Agreement Form b. New South Wales Workplace Learning Agreement Form The WorkCover Management Kit and WorkCover Management Guide are available online at: Last updated June 2008

3 DEPARTMENT OF EDUCATION & EARLY CHILDHOOD DEVELOPMENT STRUCTURED LEARNING ARRANGEMENT FORM Education and Training Reform Act 2006 Ministerial Order No. 55: Structured Workplace Learning Arrangements Student DETAILS Surname First Name Birth Date School Name and Address Postcode Telephone Teacher-in-charge of Structured Workplace Learning Student Year Level Course of study in respect of Structured Workplace Learning Skills and competencies the student is expected to obtain from the Structured Workplace Learning (attach a separate sheet) IN CASE OF EMERGENCY, THE EMPLOYER SHOULD CONTACT THE Student S PARENT OR GUARDIAN: Name: (Parent/Guardian) Address Postcode Tel. (Home) (Work) (Mobile) Emergency contact (Name and Tel.) WORKCOVER AND PUBLIC LIABILITY The student is covered for WorkCover by the Department of Education and Early Childhood Development (State of Victoria). The student is covered by public liability insurance in accordance with Ministerial Order No. 55 Structured Workplace Learning Arrangements, for the arrangement taken out by the party indicated below (principal to tick the appropriate box): Department of Education and Early Childhood Development Non-government school Employer NOTE: PUBLIC LIABILITY INSURANCE When an arrangement is entered into by a principal of: (i) a State school in respect of a State school student or by a principal of a student from a reciprocating State or Territory, the Department of Education and Early Childhood Development is obliged to hold or to take out public liability insurance to provide at least $10 million cover per event. The persons to be insured are the student and the employer. (ii) a school other than a State school that school, subject to (iii) below, is obliged to hold or take out public liability insurance to provide at least $10 million cover per event. The persons to be insured are the student and the school. (iii) a non-government school, and that school is not covered by public liability insurance as set out in (ii) above, the employer is obliged to hold or take out public liability insurance to provide at least $10 million cover per event for any loss or damage which may be caused by any act or omission of the student whilst engaged under the arrangement. In this instance, the persons to be insured are the employer and the student. EMPLOYER DETAILS [Employer to complete] PRIVACY INFORMATION: The information provided on this form is for the administration of Structured Workplace Learning Arrangements only and is not to be used for any other purpose. Health information will be provided if the student has a medical condition or requires medication that may be relevant to their employment. This information must be kept confidential. Employer (business) name Tel. Business address Postcode Type of industry Primary activity at workplace Student s work location address Postcode Workplace contact person Supervisor Activities the student will undertake (if insufficient space, attach separate sheet) Structured Workplace Learning hours am/pm, to am/pm; on Monday Tuesday Wednesday Thursday Friday from (commencement date) to (completion date) Total number of days Rate of payment $ per day ($5.00 per day minimum) EMPLOYER ACKNOWLEDGEMENT [Employer to sign] I, [name of individual, or on behalf of the employer if employer is an incorporated body) agree that: 1. I understand occupational health and safety legislation and standards relevant to the conduct of my undertaking under Victorian law and will comply with these laws and standards with respect to the student as if the student were my employee. 2. I will identify all hazards relevant to the conduct of my undertaking and will assess and control all related risks. If I have not controlled all related risks I will inform the school of this fact prior to the Structured Workplace Learning period commencing. 3. I have read and understood Department of Education and Early Childhood Development Structured Workplace Learning Guidelines for Employers. I will ensure that required planning, induction, supervision and safe systems of work are provided for the student to maintain a safe and healthy Structured Workplace Learning at all times.

4 4. I will consider and take into account the competency, maturity and physical capabilities of the student in relation to all activities he or she will undertake. The student s program of activities will be planned and carried out with these considerations in mind. 5. I will nominate a supervisor (or supervisors) of the student who will be responsible for ensuring that my obligations as the student s employer are carried out. 6. I will provide appropriate information, training, instruction and supervision to the student in respect of occupational health and safety and will provide any equipment and/or clothing which is required to comply with my duty of care toward the student. 7. I will ensure that the Structured Workplace Learning is undertaken in a non-discriminatory and harassment free environment. 8. I will permit access to the workplace and contact with the student by the principal or their representative at any reasonable time during the Structured Workplace Learning period. 9. I will ensure that the Structured Workplace Learning arrangement is not used as a substitute for the employment of employees and/or the payment of appropriate wages. 10. I will ensure that the maximum number of Structured Workplace Learning students at the place of work does not exceed one student for every three full-time employees (or part thereof). 11. I will notify the teacher-in charge of Structured Workplace Learning as soon as is possible if the student is absent, injured or becomes ill in the course of undertaking the Structured Workplace Learning. 12. I will consult with the teacher-in-charge of Structured Workplace Learning if I consider it necessary to terminate the arrangement before the specified time. I understand and accept the responsibilities set out above. Following the principal s review of these details, I understand that he or she can determine whether or not the student will undertake the Structured Workplace Learning proposed here. Signature Date Student AGREEMENT I, agree to take part in this Structured Workplace Learning Arrangement and to: carry out all reasonable and lawful directions of the employer and perform my work to the best of my ability; comply with all reasonable workplace rules and requirements governing safety and behaviour; attend at the workplace on each day at the agreed time; inform both my employer and the teacher-in-charge of Structured Workplace Learning as soon as possible if I am unable to attend work; promptly inform the employer of any accident, injury or incident that may occur; dress appropriately for the workplace. I agree that no payment will be made to me if the placement is with a Commonwealth Department or a body established under a Commonwealth Act. I give my consent to donating back the payment where an educational, charitable or community welfare organisation not conducted for profit requires that I do so as a condition of engagement. I understand that the principal can determine whether or not I will undertake Structured Workplace Learning. I acknowledge that prior to entering into this arrangement I have completed the occupational health and safety program that is part of the accredited course of study that I am undertaking. Student s signature Date PARENT/GUARDIAN AGREEMENT & CONSENT (Not necessary if the student is over 18 years) I, consent to my child taking part in this Structured Workplace Learning arrangement and I: agree that he or she will be subject to the direction and control of the employer and nominated workplace supervisor(s); understand that all reasonable care for the health and safety of my child will be taken by the employer and nominated workplace supervisor(s); give consent for my child to undertake vehicle travel with the employer or nominated workplace supervisor(s) if this is required to move from one work location to another in the course of the Structured Workplace Learning; understand that I will be notified as soon as possible in the event of illness of or accident to my child, but where it is impracticable to communicate with me I authorise the person in charge at the workplace of the employer to consent to my child receiving such medical and surgical treatment (including the administration of an anaesthetic) as may be deemed necessary by a legally qualified medical practitioner; expect my child to comply with all reasonable workplace rules and requirements governing safety and behaviour; agree that no payment will be made to my child if the placement is with a Commonwealth Department or a body established under a Commonwealth Act; give my consent to my child donating back the payment where an educational, charitable or community welfare organisation not conducted for profit requires this as a condition of engagement; attach details of any known medical condition which may affect my child, and any medication or treatment which may be relevant. I understand that the principal can determine whether or not my child will undertake Structured Workplace Learning. Signature Parent or Guardian Date (Attach details of any known medical condition which may affect this student, and any medication or treatment which may be relevant.) PRINCIPAL CONSENT I, principal of enter into an arrangement for the above named student of this school to be engaged for the purpose of Structured Workplace Learning by the employer named above in accordance with the provisions of the Education and Training Reform Act 2006 and the Ministerial Order No. 55 Structured Workplace Learning Arrangements on the basis of the information provided above and the employer s acknowledgements. I confirm that I have informed the employer as to whether this school holds public liability insurance. I confirm that the above mentioned student has completed the required occupational health and safety program prior to entering into this arrangement. Principal s signature Date

5 DEPARTMENT OF EDUCATION AND EARLY CHILDHOOD DEVELOPMENT STRUCTURED LEARNING GUIDELINES FOR EMPLOYERS Ministerial Order No. 55 WHAT IS STRUCTURED WORKPLACE LEARNING? Structured workplace learning involves students in structured on the job training during which they are expected to master a designated set of skills and competencies related to courses accredited by the Victorian Qualifications Authority. WHAT IS YOUR DUTY OF CARE AS AN EMPLOYER? You have legal obligations to provide a safe and healthy working environment for your employees and contractors. Students undertaking structured workplace learning are no different. They are owed the same duty of care, and you must take all the same steps to safeguard them during their structured workplace learning. You must assess your workplace to determine which activities can be safely managed. Students should be given tasks which are interesting and which will give them an understanding of your business. However, you must take care NOT to place them at risk, and you must provide supervision at all times. WHAT CAN YOU EXPECT OF THE Student? Remember that young people cannot be expected to possess the judgement or maturity of older workers. You have a right to require the student to comply with workplace rules and procedures. First, though, you must explain those requirements and provide any necessary information, instruction and training. Don t assume a student will automatically know what s expected! THE IMPORTANCE OF PLANNING The most rewarding structured workplace learning programs and the safest are those planned in advance. It s useful to draw up a timetable for students before they arrive, setting out proposed activities for each day and identifying the people who will supervise them at different times. Even though your timetable may have to change, a planned program enables supervisors to prepare meaningful activities, and reduces the chances of exposing the student to risks resulting from unplanned activity. SAFE SYSTEMS OF WORK Your safe systems of work should already be built on knowing your hazards, assessing the risks they present and taking steps to control those risks. Your employees will know the risk controls, but your structured workplace learning student will not. It s important to take time to explain to the student what the hazards are, why the risk controls are in place and how they are put into practice. INDUCTION AND SUPERVISION Students will not be familiar with the workplace, or the way things are done. Like any new starter, it will take them a few days to remember names and find their way around. The first thing you must do on their first morning with you is induct the student. This should be done by the employer or the nominated supervisor don t assume that induction will happen if you have not given someone specific responsibility for it! Take it slowly, and reinforce key information (eg supervisory arrangements, no-go areas and excluded activities). The following are the must do elements when introducing a student to your workplace:

6 INTRODUCTIONS AND RESPONSIBILITIES The student may be supervised directly by more than one person during the week. Introduce those who are available, and make a note of people the student will need to catch up with later. Inform the student that their health and safety is your most important concern during their stay. Explain your legal duty of care for them, and that in turn they must observe any requirements you have established to safeguard employees and others. If there is a Health and Safety Representative at the workplace, arrange a time for them to discuss their function with the student. EXPLAIN SUPERVISORY ARRANGEMENTS Students must report directly to their supervisor when entering, leaving and returning to the work location. Consider the skills and experience of people nominated as supervisor(s) will they be able to answer questions and provide the right information and instruction to ensure the student understands the tasks they are given and can undertake them safely? Explain during induction what the student should do if their supervisor is not present at any time and who they will report to. EXPLAIN ARRANGEMENTS FOR FIRST AID AND EMERGENCIES Tell the student who their first aider is, and what to do if they need first aid. Explain emergency arrangements, and point out the evacuation plan and muster points. In an emergency, the student must follow direction from their supervisor or from identified wardens. EXPLAIN HEALTH AND SAFETY REPORTING REQUIREMENTS Incidents and accidents must be reported to the supervisor without delay. Incidents include near misses, even if no-one was injured. Accidents including even minor cuts and scrapes requiring only a bandaid must be reported and recorded. Explain to the student how this is done, and encourage them to raise any health or safety concerns with their supervisor. If the student feels there might be risk in any activity, they must understand that they should not continue with the task. PROVIDE AN ORIENTATION TOUR OF THE WORKPLACE If the student will be located in one area through the week, show them home base first. It s a good idea to return to that work location from different areas each time, to assist the student to build a mental picture of the workplace layout. You should explain what happens in each part of the workplace, and point out locations where the student may be working during the week. Explain why certain areas may be deemed no-go for the student. If hazardous operations mean an area is restricted, you may want to observe the activity from a safe vantage point and describe the operations. If personal protective equipment is necessary to enter the area, this must be provided and you must explain how to use it. WORKPLACE BULLYING, HARASSMENT AND DISCRIMINATION You must explain your workplace policy regarding bullying, harassment and/or discrimination. Encourage the student to report any concern directly to the employer or their supervisor or to their teacher. CONFIRM STUDENT S MEDICAL INFORMATION Check that you have necessary medical information. Does the student have any condition (eg asthma or epilepsy) that could require treatment? Are they taking any medication? (The information must be kept confidential as far as is practicable.) Creating an induction checklist and a timetable will help you to provide a safe and rewarding work placement! Please check and follow the links.

7 A GUIDE FOR EMPLOYERS Decoder DEECD Department of Education and Early Childhood Development TAFE Technical and Further Education VCAL Victorian Certificate of Applied Learning VCE Victorian Certificate of Education VET Vocational Education and Training Structured workplace learning has enormous benefits for students, schools and employers. It allows students to combine classroom learning with hands-on industry training and practice in the workplace. What is Structured Workplace Learning? Structured workplace learning is a component of many VET programs undertaken by VCE and VCAL students. A student may spend one day a week in the workplace or on a block release from school for a number of weeks. During the work placement a student will have specific tasks to undertake in order to demonstrate competence within the VET certificate. The competencies may be assessed in the workplace, at TAFE or at school. Structured workplace learning is not the same as work experience. Structured workplace learning is about doing. Work experience is about observing. Benefits for employers Structured workplace learning allows employers to: Influence the training students receive before they join the workforce Recruit young students who understand the workplace for parttime, casual or full time work Enhance the skills of existing employees involved in training students Promote their enterprises and industry as a career for young people Build closer relations with schools and Privacy Legislation Victorian privacy laws, the Information Privacy Act 2000 and the Health Records Act 2001 protect the personal and health information of students. The information provided by students, parents/guardians and employers is obtained for the purposes of coordinating the structured workplace learning for a school student, in meeting the duty of care and child protection responsibilities. Benefits for Students Structured workplace learning programs enable students to: demonstrate skills and competencies related to their accredited program undertake relevant courses, which count towards their senior school certificate and articulate into further education and training try out career choices before leaving school develop contacts with potential employers be exposed to the real world of work Students undertaking structured workplace learning are expected to: complete the relevant sections of the arrangement form complete accredited training in occupational health and safety before placement. meet with the employer before commencing the placement behave like an employee as much as possible and follow the directions of the workplace supervisor discuss their experience with the employer at the conclusion of the placement. Students should be aware that they are representing their school while on structured workplace learning and must continue to observe school policies and codes of conduct. In particular, students must not use the internet or other electronic communications for accessing illegal, offensive and inappropriate material. Students should also follow general workplace rules and understand protocols regarding the internet. They should be made aware that some work placements might use sensitive information that must remain Information provided must be kept confidential. Employers are also required to only use this information for the purposes for which it is given to them. The school will store the student information securely and it will be kept for a minimum of five years after the placement has been completed.

8 Information for Employers Employer obligations broadly fall into three categories: Supervision Host employers nominate a supervisor to help the student undertake their designated tasks and master agreed skills, which are recorded and reported upon. Workplace compliance As for all other employees in an enterprise, employers must meet occupational health and safety requirements, comply with anti-discrimination legislation and follow lawful workplace practices. Appropriate occupational health and safety training and instruction must be provided to the student. This training should be related to the tasks the student will undertake during the placement. Public Liability Insurance When an arrangement is entered into by a principal of a government school, it is the obligation of DEECD to hold or take out public liability insurance to provide at least $10 million cover per event. The persons to be insured are the student and the employer. When an arrangement is entered into by a principal of a non-government school, it is the obligation of that school to hold or take out public liability insurance to provide at least $10 million cover per event. The persons to be insured are the student and the school. When an arrangement is entered into by a principal of a non-government school not covered by public liability insurance as set out above, then the employer will be obliged to hold or take out public liability insurance to provide at least $10 million cover per event for any loss or damage which may be caused by any act or omission of the student while engaged under the arrangement. The persons to be insured are the student and the employer. Assessment In some instances, after negotiation with a teacher, employers might also undertake to assess the student s performance in a designated task or tasks. Assessment can be undertaken through observing, questioning or more formal testing against performance indicators relevant in the workplace. What support is available for employers? Students undertaking structured workplace learning are supported by teachers, VET coordinators, SWL Cluster Coordinators, Local Community Partnerships and the Local Learning and Employment Networks who work with host employers and their designated workplace supervisors. Occupational Health and Safety Occupational health and safety requirements and standards under Victorian law must be complied with in regard to the student as if the student is an employee. Employers are required to provide students with appropriate training and instruction in respect to occupational health and safety. This training should relate to the tasks to be undertaken by the student during the placement. Students are now required to complete appropriate safe@work occupational health and safety modules before their placement commences. WorkCover All employers of students in structured workplace learning arrangements, pursuant to Part 5.4 of the Education and Training Reform Act 2006, are deemed to have WorkCover insurance with the authorised insurer of DEECD. This cover extends to all employers who are self-insurers. Payment The student is paid a minimum rate of $5 per day. Where the student is under the age of 18, if payment is $112 or less per week or $225 per fortnight, the employer will not be obligated to withhold tax, collect a Tax File Number declaration from the student, issue payment summaries or report payment details. Students aged 18 years and over must provide a Tax File Number declaration to the employer, who is required to withhold amounts in accordance with the tax tables (where applicable), issue payment summaries and report these payments to the ATO as they would do for their employees. Where the placement is with a Commonwealth department or body established under a Commonwealth Act, an educational, charitable or community welfare organisation not conducted for profit, the $5 per day payment will not be made. Last updated June 2008 Further Information Contact the teacher in charge of structured workplace learning at the school. School Contact Details Information on structured workplace learning can also be obtained from the following web site: General information on education can also be obtained from DEECD Information and Referral Service:

9 A GUIDE FOR PARENTS AND STUDENTS Decoder DEECD Department of Education and Early Childhood Development TAFE Technical and Further Education VCAL Victorian Certificate of Applied Learning VCE Victorian Certificate of Education VET Vocational Education and Training Structured workplace learning allows students to gain hands-on experience in an industry of their choice, while completing their academic studies. How does structured workplace learning work? Structured workplace learning is an important part of many VET programs undertaken by VCE and VCAL students. Work placement can be one day a week, or every day for several weeks, depending on the individual program. Unlike work experience, where the emphasis is on observing, structured workplace learning is about doing. Students learn specific tasks and are assessed in the workplace, at TAFE or at school. This assessment counts towards the VET certificate. Structured workplace learning enables students to: learn skills related to their VET accredited program undertake courses which count towards senior school certificate, and can be followed through into further education and training try out career choices make contact with potential employers, and experience the reality of the workplace Students must be aware that they are representing their school while on structured workplace learning, and that school policies and codes of conduct apply at all times. Students should also be aware that some workplaces use sensitive information that needs to remain private and confidential. Naturally, the use of any workplace equipment, such as the Internet, for purposes other than work is strictly forbidden. Students undertaking structured workplace learning are expected to: make sure forms are completed and signed complete the appropriate safe@work occupational health and safety modules before placement meet with the employer before starting work placement act as an employee, adhering to the rules of the workplace and directions of the supervisor, and discuss their experience with the employer at the end of the placement. Occupational Health and Safety Students are required to undertake accredited training in occupational health and safety before they commence structured workplace learning. Employers are required to provide students with appropriate training and instruction in respect to occupational health and safety. This training should relate to the tasks to be undertaken by the student during the placement. Privacy Legislation Under Victorian privacy laws, any personal and health information provided by the student will be kept confidential. Employers are also required to use this information only for the purposes for which it is given to them. The school will store the student information securely and it will be kept for a minimum of five years after the placement has been completed

10 Information For Parents and Guardians You can help prepare your child for their work placement by talking with them about work, and discussing any concerns they may have. You can also help organise safe travel to and from work. It s important to check that all forms are complete and have been signed, and that relevant medical information about your child has been provided. Throughout the work placement, discuss the day s activities with your child. If necessary, assist them to follow the correct procedure in dealing with any problems which may arise. WorkCover All employers of students in structured workplace learning arrangements, pursuant to Part 5.4 of the Education and Training Reform Act 2006, are deemed to have WorkCover insurance with the authorised insurer of DEECD. This cover extends to employers who are self-insurers. Public Liability Insurance Information on public liability insurance is included in the Structured Workplace Learning Arrangement Form. Payment The minimum rate of payment to students on structured workplace learning is $5 a day. Students will not be paid if their work placement is with a Commonwealth department or body established under a Commonwealth Act, or an educational, charitable or community welfare organisation not conducted for profit. Employer Obligations While in the workplace, a supervisor will help students refine their skills and undertake tests, the results of which will be recorded and reported back to the school. This assessment process will show that students have acquired the knowledge and skills necessary to perform certain tasks within the industry. The supervisor may assess students by observing and questioning, or by testing students work against current industry standards. All employers must comply with anti-discrimination legislation and follow lawful workplace practices. They must also meet occupational health and safety requirements and provide training that is related to the work placement. Last updated June 2008 Further Information Contact the teacher in charge of structured workplace learning at the school. School Contact Details Information on structured workplace learning can also be obtained from the following web site: General information on education can also be obtained from Education Line, Telephone:

11 WORKER S INJURY CLAIM FORM Your employer or the nominated Return to Work Coordinator at your workplace Your employer s WorkCover Agent - to find out who the Agent is check the If you are injured poster or call the WorkCover Advisory Service: freecall or (03) WorkCover Advisory Service - the VWA call centre: freecall or (03) WorkCover Assist - a free VWA service: (03) Your union FOR HELP COMPLETING THIS FORM OR FOR MORE INFORMATION CONTACT: Union Assist - a free service set up and run by the Victorian Trades Hall Council: (03) Answer all of the questions on this form. The form may be returned to you if it is incomplete 3 Sign the authority to release medical information and worker s declaration at the end of this form. The form cannot be accepted without your signature 3 Read the statement on the back of this form that explains how your personal and health information will be collected and used 3 Keep a copy of all documents for your records AS THE WORKER YOU NEED TO: 3 Notify your employer as soon as possible that you ve been injured at work, and complete the injury register at your workplace. You can also notify the Agent directly by sending them the early notification copy of this form 3 Report the accident to the police if your injury was the result of a motor vehicle accident. Otherwise your claim may not be valid 3 Give this form (when completed) to your employer as soon as possible after being injured. If you have difficulty giving this claim to your employer, or your employer refuses to take receipt of the claim form, you can send it directly to the Agent or the VWA if the Agent is not known 3 See your medical practitioner to obtain a WorkCover Certificate of Capacity (medical certificate) if you are unable to work and want to claim weekly payments, and give the original copy to your employer along with this form. It is a good idea to check that all of the injuries or illnesses that you are claiming for on this form are listed on the WorkCover Certificate of Capacity. GETTING BACK TO WORK Talk with your employer to develop a return to work plan as soon as you are aware that you will be incapacitated for more than 20 days Talk to your medical practitioner about your limitations and what parts of your work you could do. You can also encourage your medical practitioner to talk to your employer about aspects of your work you could do and any suitable duties that may be available Talk to the Agent about what support is available to help you return to work and overcome your injury as quickly as possible YOUR EMPLOYER S RESPONSIBILITIES: To confirm to you in writing that you notified them of this claim (They can also do this by giving you a copy of this form when signed and completed) If you are claiming weekly payments, they must send the completed form and any WorkCover Certificates of Capacity (medical certificates) to the Agent as soon as possible, but no later than 10 days after receiving them from you - or they may be financially penalised To pay you weekly payments if your claim is accepted and you have an entitlement To work with you to develop a return to work plan (if required), and, when you have a capacity to work, to include an offer of suitable employment To appoint a return to work coordinator to support your return to work if you are incapacitated for more than 20 days Please note that there are penalties for providing false or misleading information in relation to this claim The WorkCover Agent will write to you and advise you if your claim is accepted A decision to accept or reject your claim will usually be made within 28 days (if you are claiming weekly payments), or 60 days (if the claim is for medical and like only expenses from the time the claim is received from the Agent) To find out more about making a claim, and what support is available to help you return to work, talk to the Agent, refer to the brochure Introducing WorkCover, a guide for injured workers, or visit the website at FOR502/07/08.07 This form can be used to lodge a Workers Compensation Claim in New South Wales, Queensland, or Victoria

12 This form can be used to lodge a Workers Compensation Claim in New South Wales, Queensland, or Victoria What area of the worksite were you working in when you were injured? WORKER S INJURY CLAIM FORM Please indicate in which State you want to lodge this claim: 1 WORKER S PERSONAL DETAILS Title Given names Family Name Other known or previous legal names eg. Maiden name Date of birth Gender Male Residential street address Suburb State New South Wales Queensland Victoria Postal address for correspondence Female Postcode What is the street address where the incident occurred? Suburb State Name of employer responsible for this workplace Which of the following incident circumstances apply? While working at your usual workplace While working away from your usual workplace During a meal-break or authorised recess at work While away from work during a recess Travelling to or from work* A motor vehicle accident while you were working* * For NSW incidents a journey claim form must also be completed If your injury was the result of driving or using a motor vehicle or the use of public transport, please provide the following details: The police station the accident was reported to Registration number/s of involved vehicles State What are your daytime contact phone number/s? M W H address Do you believe that your injury/condition was caused or contributed to by a third party such as a manufacturer or supplier? Please give details if relevant If you need an interpreter, what language do you speak? Do you have special communication needs because of disability? eg. Hearing or vision impairment * These questions are required for NSW claims * Do you support a partner? Yes No * If yes, what were their average gross weekly earnings over 3 months? $ * Do you support any children under the age of 18, or full-time students? Yes No * If yes, please provide the date of birth for each What was the date and time the injury/condition occurred? AM PM When did you first notice the injury/condition? If you stopped work, what was the date and time? AM PM When did you report the injury/condition to your employer? What is the name and position of the person you reported the injury/condition to? 2 INCIDENT & WORKER S INJURY DETAILS What is your injury/condition, and which parts of your body are affected? If you did not report the injury/condition, or there was a delay, please explain why What happened and how were you injured? What are the names and daytime contact details of anyone who witnessed the incident? Have you previously had another injury/condition or personal injury claim that relates to this injury/condition? Please give details, including claim numbers What task/s were you doing when you were injured?

13 This form can be used to lodge a Workers Compensation Claim in New South Wales, Queensland, or Victoria If you have returned to work with your employer, 3 WORKER S EMPLOYMENT DETAILS Name of organisation paying your wages when you what was the date? were injured What duties are you doing? Full Suitable/Modified Street address of your usual workplace Suburb How many hours are you working? Have you returned to work with a new employer? Please provide the name and contact details of the new employer hrs State Postcode Name and daytime contact number of employer contact eg. Name of return to work coordinator If you have not returned to work, do you think that there are any issues that would delay or prevent you from returning to work? What is your usual occupation? What do you do? Which of the following apply to you? (Please tick all relevant boxes) Casual Student Full-Time Part-Time Apprentice Volunteer Contract Trainee Agency worker Contractor Permanent Temporary Seasonal Jockey Other? When did you start working for this employer? Please indicate if any of the following apply to you: Yes No A Director of my employer s company Yes No A Partner in my employer s company Yes No A sole trader Yes No A relative of my employer Did you have any other employment at the time you were injured? Please provide or attach the names of any other employers and their contact details, and any relevant wage or payment records 4 WORKER S PRIMARY EARNING DETAILS Please complete this section if you wish to claim for weekly payments How many standard hours did you work each week before being injured? Exclude overtime What were your usual working hours? For example, Monday to Friday, 8.30 am to 5.30 pm What was your usual pre-tax hourly rate?* Exclude overtime & shift allowances What were your usual pre-tax weekly earnings?* Exclude overtime & shift allowances $ * Please provide copies of any recent payslips (if available) Please provide details of any overtime or shift work Weekly shift allowance Weekly overtime hrs $ $ 5 TREATMENT & RETURN TO WORK DETAILS * This question is required for NSW claims * Who is your nominated treating doctor? Name Phone Please provide the name, clinic or hospital, and contact details of any medical providers (including Clinics or Hospitals) that have treated your injury $ hrs When did/will you give your employer this claim form? 6 AUTHORITY TO RELEASE MEDICAL INFORMATION AND WORKER S DECLARATION 7 EMPLOYER LODGEMENT DETAILS When did the employer first receive the worker s completed claim form? When did the employer first receive the worker s medical certificate? *This question is required for Victorian claims Date claim form forwarded to Agent Estimated cost of claim to date How many days have been lost? Employer s signature Name Position How did/will you give this claim form to your employer? Hand delivery By post When did/will you give your employer the first medical certificate? I have read the information provided in this form. I declare that the information that I have supplied in this form, and any attachments to this form, is true and correct to the best of my knowledge. I understand that the making of a false or misleading claim or false and misleading statement in support of the claim is punishable by law and that I may be prosecuted. I authorise and consent to any person who provides a medical service or hospital service to me in connection with an injury/condition to which this claim relates to provide upon request by the workers compensation authority, my employer or insurer/claims agent, any information regarding the service relevant to the claim. I understand that my authority has effect and cannot be revoked for the duration of this claim. Worker s signature Date * This declaration is also required for NSW claims I authorise and consent to the collection, disclosure and release of any personal and health information in connection with an injury/condition to which the claim relates by the workers compensation authority, my employer or insurer/claims agent to each other, or to any person who provides a medical service or hospital service to me in connection with an injury/condition to which this claim relates. I understand that if this claim results in my receiving weekly compensation payments, I am required to notify whomever is paying my benefits if I commence employment with some other person or in my own business, or of any change in my employment that affects my earnings, and that failure to do so is an offence. I consent to the WorkCover Authority of NSW using the information collected in connection with my claim for the purposes of research about workers compensation, workplace injury management and occupational health and safety. Worker s signature Date Date $ days hrs Employer s scheme registration number eg. WorkCover Employer, Policy, or Employer Registration Number ORIGINAL

14 ACCIDENT COMPENSATION ACT 1985 WORKER S INJURY CLAIM FORM COLLECTION OF PERSONAL AND HEALTH INFORMATION TO MANAGE YOUR CLAIM* In processing your claim, the Victorian WorkCover Authority (VWA) and any WorkCover Agent acting for the VWA in relation to your claim may collect personal and health information about you. The VWA and Agents are required by law to ensure that all people about whom they collect personal and health information are provided with the following information: The VWA is a body corporate established under the Accident Compensation Act Agents are appointed by the VWA under that Act to act on its behalf in managing workers compensation policies and claims for compensation. Personal and health information about you is collected on this form and may also be collected during the processing, assessing and management of your claim. It may be collected from your current, previous and future employers, other government agencies, credit reporting agencies, health service providers and other persons who can provide information relevant to the claim. Personal and health information about you also may be collected by solicitors, private investigators, loss adjusters and other service providers acting on behalf of the VWA or your employer s Agent. Personal and health information collected about you is used for the purpose of processing, assessing and managing your claim and to verify any evidence you may submit in support of the claim. The information may also be used for one or more of the purposes listed in section 243 of the Accident Compensation Act 1985, for the purposes of legal proceedings arising under that Act, to assist with your rehabilitation and return to work and to assist the VWA and WorkCover Agents to better manage claims generally. For the purposes of processing, assessing and managing your claim, the VWA and your employer s Agent may disclose personal and health information about you to each other and to the following types of organisations: employees, contractors and agents of the VWA and the VWA s Agents your employers solicitors, medical practitioners and other health service providers, private investigators, loss adjusters and other service providers acting on behalf of the VWA or the Agent in relation to the claim the Accident Compensation Conciliation Service and Medical Panels a court or tribunal in the course of criminal proceedings or any proceedings under any of the Acts which the VWA administers any other person, organisation or government agency authorised by you, or by law, to obtain the information. Collection of this information may be required by the Accident Compensation Act If you do not provide any part or all of this information, your claim may not be accepted or processed. You may request access to personal and health information about you collected by the VWA or your employer s Agent by contacting your employer s Agent. The VWA s policies for managing personal and health information are set out in its Privacy Policy, which is available from your nearest VWA office or at Information relating to your right to access your WorkCover claim information is also available at the website. (*If your injury employer is an approved self-insurer, where you read VWA and Agent also read self-insurer and approved agent of a self-insurer.)

15 ORIGINAL OCCUPATIONAL HEALTH AND SAFETY ACT 2004 May 2007 WORKSAFE VICTORIA INCIDENT NOTIFICATION FORM OCCUPATIONAL HEALTH AND SAFETY ACT 2004 Office use only Reference Number Ring to obtain a Reference Number. The Reference Number is your proof of immediate notification. Immediate notification is required under section 38(1) of the Occupational Health and Safety Act Person Submitting Details (Please print in BLOCK letters) Name Position Title Telephone Number Date Date of Incident Time of Incident Name of Employer / Self Employer Business Address (Not P.O. Box) Postcode Name of Employer of Deceased / Injured Person(s), if any, if different from above Address of Premises where Incident Occurred Brief Description of Incident (Give Details of the type of Injury, if any, caused by the Incident) Details of Deceased / Injured Person(s) Name Male Female Residential Address Postcode Date of Birth Occupation / Job Title / Description Telephone Number Employee / Contractor / Member of Public Work / Activity being undertaken at Time of Incident (Identify any Plant, Substance, Equipment Involved) Person(s) who saw Incident or first came to Scene Action Taken / Intended, if any, to prevent recurrence of Incident The above information is to be provided to the extent that it is known at the time of writing Declaration I declare that where I provide personal or health information to the Victorian WorkCover Authority (VWA) about any other individual, I am authorised to provide that information, the information has been collected in accordance with applicable privacy legislation and the individual has been or will be made aware of the VWA s identity and how to contact it and of the other matters of which an individual is required to be made aware when personal or health information is collected about them. Signature Date Name Optional WorkCover ID Establishment No

16 EMPLOYER COPY OCCUPATIONAL HEALTH AND SAFETY ACT 2004 May 2007 WORKSAFE VICTORIA INCIDENT NOTIFICATION FORM OCCUPATIONAL HEALTH AND SAFETY ACT 2004 Office use only Reference Number Ring to obtain a Reference Number. The Reference Number is your proof of immediate notification. Immediate notification is required under section 38(1) of the Occupational Health and Safety Act Person Submitting Details (Please print in BLOCK letters) Name Position Title Telephone Number Date Date of Incident Time of Incident Name of Employer / Self Employer Business Address (Not P.O. Box) Postcode Name of Employer of Deceased / Injured Person(s), if any, if different from above Address of Premises where Incident Occurred Brief Description of Incident (Give Details of the type of Injury, if any, caused by the Incident) Details of Deceased / Injured Person(s) Name Male Female Residential Address Postcode Date of Birth Occupation / Job Title / Description Telephone Number Employee / Contractor / Member of Public Work / Activity being undertaken at Time of Incident (Identify any Plant, Substance, Equipment Involved) Person(s) who saw Incident or first came to Scene Action Taken / Intended, if any, to prevent recurrence of Incident The above information is to be provided to the extent that it is known at the time of writing Declaration I declare that where I provide personal or health information to the Victorian WorkCover Authority (VWA) about any other individual, I am authorised to provide that information, the information has been collected in accordance with applicable privacy legislation and the individual has been or will be made aware of the VWA s identity and how to contact it and of the other matters of which an individual is required to be made aware when personal or health information is collected about them. Signature Date Name Optional WorkCover ID Establishment No

17 Collection of Personal and Health Information VWA is a body corporate established under the Accident Compensation Act To obtain the contact details of your nearest VWA office, visit our website at Personal and health information collected in connection with this notification will be used for the purpose of monitoring, assessing and investigating workplace incidents. The information may also be used for the purpose of administering and enforcing legislation administered by the VWA, administration and evaluation of the VWA s programs generally and legal proceedings. Subject to Section 10 of the Occupational Health and Safety Act 2004, the VWA may disclose such information to its contractors and agents, to other regulatory agencies, to a court or tribunal and to any person or organisation authorised by the individual to whom it relates, or by law, to obtain it. Collection of this information is required by the Occupational Health and Safety Act 2004 and other legislation administered by the VWA. If you do not provide any of this information, you may be subject to a penalty. Individuals have rights to have access to personal and health information the VWA holds about them: contact the VWA Freedom of Information Officer. You can access the VWA Privacy Policy at Notice of Incident Compliance with the Occupational Health and Safety Act 2004 requires an employer or self-employed person to notify WorkSafe immediately after becoming aware of an incident at a workplace which results in (a) the death of any person; or (b) a person requiring medical treatment within 48 hours of exposure to a substance; or (c) a person requiring immediate treatment as an in-patient in a hospital; or (d) a person requiring immediate medical treatment for (i) the amputation of any part of his or her body; or (ii) a serious head injury; or (iii) a serious eye injury; or (iv) the separation of his or her skin from underlying tissue (such as degloving or scalping); or (v) electric shock; or (vi) a spinal injury; or (vii) the loss of a bodily function; or (viii) serious lacerations; or (e) any other injury to a person or other consequences prescribed by the regulations Notice of Incident That Exposes a Person to Risk An employer or self-employed person must notify the VWA immediately after becoming aware of an incident at a workplace which exposes a person in the immediate vicinity to an immediate risk to the person s health and safety through (a) the collapse, overturning, failure or malfunction of, or damage to, any plant that the regulations prescribe must not be used unless the plant is licensed or registered; or (b) the collapse or failure of an excavation or of any shoring supporting an excavation; or (c) the collapse or partial collapse of any part of a building or structure; or (d) an implosion, explosion or fire; or (e) the escape, spillage or leakage of any substance including dangerous goods as defined in the Dangerous Goods Act 1985; or (f) the fall or release from a height of any plant, substance or object; or (g) the following incidents in a mine*: (i) the overturning or collapse of any plant; or (ii) the inrush of water, mud or gas; or (iii) the interruption of the main system of ventilation; or (h) any other event or circumstance prescribed by the regulations. *Any notifiable incidents occurring in a mine must be reported to the Department of Primary Industries (DPI) in lieu of the Authority. In addition, any notifiable incidents in a quarry must be reported to the DPI in lieu of the Authority. The contact details for the DPI are set out below. In addition to the notification, the employer must provide a written record of the incident using this form to the VWA (or the DPI if the incident occurs at a mine or quarry) within 48 hours. Site Preservation The incident site must not be disturbed until an inspector arrives or until directed by an inspector except to protect the health and safety of a person; or provide aid to an injured person involved in the incident; or to take essential action to make the site safe or prevent a further incident. The Occupational Health and Safety Act 2004 Requires You to: 1. Notify WorkSafe immediately on Keep a copy of the form for at least 5 years; 3. Send this Incident Notification Form to WorkSafe within 48 hours: by post to the WorkSafe Incident Notification Coordinator GPO Box 4306, Melbourne 3001; or by facsimile to (03) ; or to WorkSafe, 222 Exhibition Street, Melbourne 3000 Contact Details for Notification to the DPI: 1. Ring the DPI District Manager in the relevant District:- South Western District BH (03) AH Melbourne District BH (03) AH Gippsland District BH (03) AH North East District BH (03) AH North West District BH (03) AH or the Manager, Minerals and Extractive Operations, on BH (03) or Mobile Send a written incident notification form to the DPI within 48 hours: by post to The Manager Minerals and Extractive Operations, Department of Primary Industries, GPO Box 4440, Melbourne 3001; or by facsimile to (03) ; or to DPI reception, level 16, 1 Spring Street, Melbourne Vic WorkSafe Victoria is a division of the Victorian WorkCover Authority. FOR537/09/05.07

18 Sample Record of Contact Form for Structured Workplace Learning Schools are required to contact students on structured workplace learning placement as part of their duty of care under legislation. The principal should nominate a coordinator, teacher or delegate to act on behalf of the school. The contact may be by telephone or by workplace visit (including in term breaks). Open-ended questions should be used wherever possible and a Record of Contact Form completed. It is important that students are able to provide feedback privately. If a telephone approach is used, ensure that the student can talk in private. Date: Name of student: Workplace details: School name: Contact person name: Orientation Have you had any problems getting to the workplace [if so, how have you resolved them]? How are you settling in to the workplace? Are you clear about the things expected of you at the workplace? Planned school tasks Have you talked to your supervisor about your planned work requirements [and have they been scheduled into your experience]? What have you learned, and what tasks have you performed? (This question is intended to elicit potential high risk industry issues with regard to use or operation of equipment) Satisfaction Level How would you describe your experience so far? What have you done so far that you feel you have done well? Was there anything you thought you could do better or improve? Feedback Do you have any worries or concerns about any aspect of your workplace, or about any individual at the workplace? (This question is intended to give the student the opportunity to raise any discrimination, harassment or bullying issues) Is follow-up contact required? YES NO Contact Person (signature) Sample Record of Contact Form for Structured Workplace Learning Last updated June 2008

19 Details of Structured Workplace Learning involving accommodation away from home (this form is for INTERNAL school use only) Name of School Tel Fax Address Postcode Name of Student Date of Birth Year PLACEMENT DATES: From To Type of Work Name of Employer Address Postcode Contact person Telephone Fax Travel arrangements to and from workplace OVERNIGHT ACCOMMODATION: Person supervising Relationship to student Address Postcode Telephone: Business Hours After hours Travel arrangements to and from home PARENT/GUARDIAN STATEMENT: I APPROVE OF THE ABOVE STRUCTURED WORKPLACE LEARNING ARRANGEMENT AND ALL ARRANGEMENTS INCLUDING PROPOSED TRAVEL AND ACCOMMODATION PROVISIONS. Parent/Guardian: Name Signature Date FOR SCHOOL USE ONLY: Please outline the reasons for the structured workplace learning, including the educational value of the experience and the lack of opportunity in the local community: What steps has the school taken to ascertain that the structured workplace learning, overnight accommodation and travel arrangements satisfy safety and welfare requirements? What arrangements have been made to monitor the student s progress during the structured workplace learning? Structured workplace learning Coordinator Name Signature Date Principal: Name Signature Date Please ensure the student has been given a 24 hour school contact person and phone number.

20 WORK EXPERIENCE/STRUCTURED WORKPLACE LEARNING FOR VICTORIAN PUPILS WITH NEW SOUTH WALES EMPLOYERS (ASSUMING NO ACCOMODATION AWAY FROM HOME) This placement application is for: Work Experience Structured Workplace Learning PUPIL DETAILS Surname Given Name Birth Date Student s Parent/Guardian Name Address Telephone(Work) Home SCHOOL DETAILS School Name Address Name of Principal Name of Work Experience/Placement Coordinator Phone Fax HOME SCHOOL APPROVAL Principal s Signature Date EMPLOYER and PLACEMENT DETAILS Business Name Address Phone Fax Business Registration No: Name of Workplace Supervisor Position Dates of Placement: From To Proposed Industry Focus Area Course of Study in Respect of Work Placement Employer s Signature Date PARENT/GUARDIAN PERMISSION I consent to my child/ward (name of student) taking part in the above work experience/structured workplace learning according to the conditions and guidelines of the New South Wales Department of Education and Training. I understand that no payment is involved and that the student is a volunteer worker, not an employee of the above employer, the Victorian Department of Education and Early Childhood Development or the New South Wales Department of Education and Training. Parent/Guardian Signature Date HOST STATE APPROVAL Placement Approved / Not Approved If Approved: The New South Wales Department of Education and Training Work Experience/Work Placement insurance and indemnity provisions will be extended to cover for the above-mentioned period. A copy of the Employers Guide to Work Experience is attached. Supervision will be the responsibility of the Home School. Name: Position: Signature: Date: