Host Employer Details

Name of Organisation (Trading Name)

Address

Suburb

State

Post Code

Postal Address (if different)

Contact Person

Position

Contact number

Mobile

Email

Website

Please provide your organisation’s ABN below:(Required.)

ABN

Does your organisation hold current Public Liability Insurance?(Required.)

Yes

No

Please provide the below details of your current Public Liability Insurance

Policy Number

Expiry Date

Supervisor Details (must not be a trainee or apprentice)

First Name

Surname

Position

Contact number

Email

Overview of your business

Type of industry

Main activity

Approx. no. of employees at proposed worksite

Approx. no of years in current operation

Select one of the below

Government enterprise

Private enterprise

Self-employed

Other (please specify)

Attendance Details

Start Time

Finish Time

Break Times

If one day per week list day

Has your business hosted students for work experience or work placement in the last 12 months?

Yes

No

List the required dress attire for the student attending Workplacement at your business

List the activities to be undertaken by the student

List activities that the student must not undertake. This includes no-go areas, specific machinery and equipment that is dangerous for new or young workers. Please note an extensive risk assessment must be completed for horse riding and the use of farm vehicles.

List any risks to the student in planned activities, please be specific. This includes manual handling, exposure to sun, chemicals, fumes, repetitive strain injuries and the use of dangerous tools or equipment.

How will the listed risks be eliminated or controlled, eg. induction first day, close supervision, tasks are demonstrated and supervised to completion.

List any special conditions such as clothing, footwear, pre-training, vaccinations or student travel with host employer.