Work Experience Form 2022

Blundell’s School
Work Experience 2021/2022
Blundell’s School Work Experience Form for ‘in person’ Placements 2022
Details of Student
Full name of Student Archie Joyner
Name of Company / Employer Fieldhouse Engineering
Date of Work Experience Placement 4th July
Date of birth and Age of Student DOB 13.03.2006 Age 16

on 1st day of placement
Any medical conditions for the Employer to be

aware of? No
How did you find this placement? Family

Friend
Other personal contact
Website
School
Other (please specify)
Where will you stay during the placement? At home
How will you travel to/ from the placement

each day? My parents will take me
Contact details for Student’s parent or guardian
1
Name of Parent / Guardian 1. Amelia Joyner
2. Simon Joyner
Contact number
Mobile 1 - 07747866602
Mobile 2 – 07912 632535
Signature of the Parent or Guardian

giving approval for this placement (on behalf Amelia Joyner
of both parents)
Date 12.6.2022
Page 1 of 4
For the placement provider to complete

Placement Provider / Company Name
Name of person responsible for the

student during the placement
Job title / Position within the company
Contact Number/s of Supervisor
Contact Email address
Dates of Placement
Hours of Work
Address of Company
Location of placement (if different to

above)
Will the student be staying overnight? Yes / No

Have you had any other Work Experience students in the
recent past? When?
Is it possible for a member of staff to visit the student
during the placement? Yes / No
Do you confirm that you have responsibility for the
student’s safety and welfare, as for a normal employee? Yes / No
Do you confirm that you have implemented and comply
with all Government guidance on COVID-secure Yes / No
workplaces applicable at the time of the placement? This
must cover young people carrying out placements.
Do you have policies and procedures in place to protect Yes / No

children from harm?
If Yes, please give details.
2
You agree to brief student on arrival:
Yes / No
Risk, PPE, Conduct, Tasks, Timings, Accidents, Asking
questions, Reporting, expectations during the
placement
Can you confirm that you have notified your Insurer that
there will be a young person on site and your existing Yes / No
Employers’ Liability Policy and Employers’ Public Liability
will cover this work placement?
Page 2 of 4
What tasks can the student be expected
to carry out during the placement?
Will all tasks be within the capabilities of

the student (consider their age and any Yes / No
special educational needs of the
student)?
The placement provider’s Risk Assessment needs to cover the placement student. Please read and
understand the Health and Safety Executive, Young People and work experience – a brief guide to
health and safety for employers. https://www.hse.gov.uk/pubns/indg364.htm
Has your existing Risk Assessment been

recently reviewed during COVID-19 to Yes / No
include a young person for work
experience placement?
A student should not be left alone with an Employer/ supervisor or company representative/
member of staff for a substantial period of time. For students under 16, the Company/ Employer
should consider enhanced Disclosure and Barring Service (DBS) checks with barred list
information, if the Supervisor or another employee will be working alone with the student
frequently/ for more than a brief period of time/ if the placement involves a lot of travelling/ if
the placement is in an isolated environment/ not in an open or visible office or space.
Any scenarios which will involve or are likely to involve an employee or manager spending
substantial time alone with a student under 16, where an enhanced DBS with barred list check
may be necessary, should be reported to the School who will make a determination as to whether
such a DBS and barred list check is necessary.
For staff supervising students aged 16 and 17, Employers are not able to carry out an enhanced
DBS check with children’s barred list information. Schools are therefore not able to request that
an employer obtains an enhanced DBS check with children’s barred list information for staff
supervising children aged 16 to 17 on work experience.
ONLY COMPLETE THIS QUESTION IF A 1. Enhanced DBS with barred list check is
DBS CHECK OF THE SUPERVISER (AND/ required and already in place.
OR OTHER EMPLOYEES) MAY BE
REQUIRED. PLEASE SEE SECTION ABOVE 2. Enhanced DBS with barred list check may be
FOR FURTHER INFORMATION. required but not yet in place.
3
Please circle only one of the following 3. Enhanced DBS with barred list check is not
options which applies to DBS checks for required. I confirm that the supervisor is not
the supervisor (and/or other employees) barred from dealing with children.
of this placement.
Page 3 of 4
Does the student require an appropriate level DBS Yes / No
check? You should consider the nature of work to be
undertaken by the student. If it is a ‘regulated activity’
a DBS check will be required. Students under 16 do
not require a DBS check.
Are there any other young people in the company?

Yes / No
Will the tasks for work experience be low risk,

medium risk or high risk? Low / Medium / High
Please see the Health and Safety Executive website For Medium or High explain why you
(www.hse.gov.uk) for information on assessing the have assigned this risk level.
level of risk and
https://www.hse.gov.uk/pubns/indg364.pdf
The School will check any placements deemed

medium or high risk.
The placement provider will provide any necessary
PPE. Yes / No / Not necessary
The placement provider will immediately inform

parents and the School if there are any concerns, near Yes / No
misses, incidents or complaints.
The placement provider invites feedback and

reporting, and will complete a short report on the Yes / No
student.
Signature of Employer
Print Name
Date
Any other useful information regarding the placement.
Any questions to Ms Parkinson c.parkinson@blundells.org

School Use only
Date Received and Checked; All medium and high-risk placements checked; Record of Contact; Visit arranged
4
Page 4 of 4

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Blundell’s School

Work Experience 2021/2022

Full name of Student Archie Joyner

Name of Company / Employer Fieldhouse Engineering

Date of Work Experience Placement 4th July

Date of birth and Age of Student DOB 13.03.2006 Age 16

Any medical conditions for the Employer to be

How did you find this placement? Family

Where will you stay during the placement? At home

How will you travel to/ from the placement

Contact details for Student’s parent or guardian

Mobile 2 – 07912 632535

Signature of the Parent or Guardian

For the placement provider to complete

Name of person responsible for the

Contact Email address

Location of placement (if different to

Will the student be staying overnight? Yes / No

Do you have policies and procedures in place to protect Yes / No

Will all tasks be within the capabilities of

Has your existing Risk Assessment been

Are there any other young people in the company?

Will the tasks for work experience be low risk,

The School will check any placements deemed

The placement provider will immediately inform

The placement provider invites feedback and

Any other useful information regarding the placement.

Any questions to Ms Parkinson c.parkinson@blundells.org

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