Student No. Student First Name Student Last Name Role Title Start Date Finish Date Benefits --None-- Expenses Accommodation Food Other Other Benefits Proposed Placement Tasks Format of Placement --None-- Wholly remote Hybrid Wholly in-person Length --None-- Hours Days Weeks Total Duration (days) HESA Activity Type --None-- Paid Work Unpaid Work Turing Scheme International Learning Exchange Programme Name Location --None-- UK Overseas Main Switchboard Number Street City County Country Post Code First Name Last Name Job title Telephone Email Address Have you attended the mandatory on-campus health & safety/ academic assignment briefing session that takes place before the start of the placement? --None-- Yes To follow Have you received health & safety information from your placement employer? --None-- Yes No To Follow Have you reviewed the Module Guide (including the deadlines for each assignment) and the Placement Guide along with emergency contact details on Moodle? --None-- Yes To follow As far as you are aware, how would you rate your travel and transportation risks? --None-- LOW:No significant Travel MEDIUM: Long daily commute / regular driving / night travel HIGH: Demanding travelling / driving unfamiliar vehicles / driving others Travel/transportation factors what risk(s) have you identified and what will you do to mitigate these? If nothing is required, please put N/A As far as you are aware, how would you rate your working environment? --None-- LOW: Office/ business environment MEDIUM: Industrial/ workshop/ building site/ kitchen environment with in- house training provided HIGH: Working with hazards that have the potential to cause permanent injury or fatalities such as operating heavy machinery Work factors what risk(s) have you identified and what will you do to mitigate these? If nothing is required, please put N/A As far as you are aware, how would you rate the general health and safety risks associated with work place activities? --None-- LOW: No significant health risks MEDIUM: Some precautionary measures (such as optional inoculations/ medical travel kits HIGH: Mandatory and specific health protection (such as working in very hot, cold or strenuous conditions or compulsory inoculations) General/environmental health factors what risk(s) have you identified and what will you do to mitigate these? If nothing is required, please put N/A How would you rate risks associated with your personal circumstances? --None-- LOW: You have no personal factors that may cause episodes of illness and you understand the role requirements MEDIUM: You have personal factors that may require specific adjustment or support during work HIGH: You have personal factors (i.e. health, disability, linguistic or cultural) which may increase the risk of illness or accident Personal circumstances what risk(s) have you identified and what will you do to mitigate these? If nothing is required, please put N/A As far as you are aware, how would you rate the location/ regional risks? --None-- LOW: UK with no significant local risks MEDIUM: Overseas placements in low risk countries (as per the Foreign & Commonwealth Office) HIGH: Significant risk of civil disorder/ crime/ war zone areas Location factors what risk(s) have you identified and what will you do to mitigate these? If nothing is required, please put N/A As far as you are aware, how would you rate the insurance risks? --None-- LOW: UK and covered by the employer's public liability insurance (WAVES will check this) MEDIUM: Overseas and covered by the employer's liability insurance (WAVES will check this) HIGH: Overseas and not covered by the employer's liability insurance (WAVES will require proof that you have organised your own liability insurance)