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Student/Employer Field Placement Agreement
**Please ensure that the information below is completed in full and sent in for approval PRIOR to placement start date. Please email it in digital format.**
STUDENT INFORMATION
Name:
Anh Van Duc Nguyen
Student No.
N01408838
Address:
30 Nash Drive, North York, Toronto ON M3M 2L3
Email:
Anh.vdnguyen@gmail.com
Phone No.
437-522-8718
Emergency contact name and phone
Are you an international student? Yes No If yes, have you received your Co-op work permit? Yes No
2022/07/31
2022/07/31
Work Permit expiry date
PLACEMENT INFORMATION
Placement start date
January 04, 2022
End date
April 29, 2022
Total Hours (min. 320):
320
Company:
Phone:
Company Address:
Company Website:
Supervisor:
Name
Job Title
Phone
POSITION JOB TITLE
Position is (check one): PAID rate: $_____________ UNPAID (Please make sure to complete & submit WSIB forms)
Where did you find your placement? Indeed__________________________________________________________
SPECIFIC ACTIVITIES TO BE PERFORMED BY STUDENT
LEARNING OUTCOMES:
RATIONAL (Why did you choose this placement? How does it relate to your program? What outcomes do you expect & how will it affect your career?):
Employer Agreement
I, the undersigned, understand and accept the following terms and conditions:
To expose the student to a variety of duties – To complete all necessary forms and documentation
To evaluate workplace assignments – To provide a minimum of 320 hours of work
To provide the student with an orientation to their duties – To provide necessary guidance & supervision
To contact Faculty of Business Program Coordinator if problems arise
2021/12/16
Supervisor’s Signature Date Student’s Signature
Program Coordinator’s Signature Date
WSIB FORM – APPENDIX A
STUDENT DECLARATION OF UNDERSTANDING
Workplace Safety and Insurance Board (WSIB) or Private Insurance Coverage for Students on Unpaid Work Placements
The Humber College Institute of Technology & Advanced Learning and the University of Guelph-Humber (hereafter referred to as “Humber”) are committed to ensuring compliance with the Ministry of Training, Colleges and Universities (MTCU) Guidelines for Workplace Insurance for Postsecondary Students on Unpaid Work Placements.
Student coverage while on placement
The Government of Ontario, through the MTCU, covers the costs of WSIB benefits or private insurance for injuries or diseases incurred by students enrolled in an approved Ontario postsecondary program and participating in an unpaid work placement to gain work skills and experience required by their program of study.
If an Ontario student is on an unpaid work placement at an employer who is compulsorily or voluntarily covered under the Workplace Safety and Insurance Act (WSIA), the student is eligible for WSIB coverage if he/she is injured or contracts a disease while on the placement. For an unpaid work placement at an employer who is not covered by the WSIA, the student is eligible for limited private insurance (ACE-INA) coverage in the event of an injury/ disease.
Declaration
1) WSIB or private insurance coverage will be provided through the Ministry of Training, Colleges and Universities while I am on unpaid work placements as arranged or authorized by Humber as a requirement of my program of study.
2) In the event of an accident, injury or illness incurred as a result of my placement, I will immediately report the incident to the Placement Employer and to Humber. I will complete and sign the Student Placement Injury Report and the MTCU ‘s Post-Secondary Student Unpaid Work Placement Workplace Claim Form and submit to my Humber Placement Coordinator within 24 hours. Over the course of my injury or illness, I will maintain regular contact with my Placement Coordinator and provide information relating to my restrictions and ability to return to the placement.
3) In the event that a workplace insurance compensation claim is filed for an injury sustained or a disease contracted while on my work placement, Humber College will disclose my applicable personal information relating to the unpaid work placement, the WSIB claim or the ACE-INA claim to the MTCU for purposes of administration of the claim.
4) Over the course of my placement, I will participate in and implement all safety-related training and procedures required by my Placement Employer and Humber.
5) I will promptly inform the Placement Employer and my Humber Placement Coordinator of any safety concerns related to my placement.
6) My personal information, relevant to my unpaid work placement, may be disclosed by Humber to my unpaid placement employer. This information will be limited to my full name, my local address and telephone number, my placement schedule (i.e. the days I will be at the placement), and my acceptance of the conditions of the placement.
I have read and understand the above, and have had any questions answered to my satisfaction:
Student Name: Anh Van Duc Nguyen Student Number: N01408838 Program: Global Business Management
Signature: Date: 2021/12/16
Parent/Legal Guardian’s Signature (for student less than 18 years of age):
Name: Signature: Date:
Distribution
• Students must return the original signed letter to their Humber Placement Advisor.
• Students are encouraged to keep a copy for their records.
WSIB FORM – Appendix B
LETTER TO PLACEMENT EMPLOYER
Process for Workplace Safety and Insurance Board (WSIB) or Private Insurance Coverage for Students on Unpaid Work Placements
The Humber College Institute of Technology & Advanced Learning and the University of Guelph-Humber (hereafter referred to as “Humber”) are committed to working with placement employers to implement the Ministry of Training, Colleges and Universities (MTCU) Guidelines for Workplace Insurance for Postsecondary Students on Unpaid Work Placements. The MTCU guidelines require Humber to notify the Placement Employer about workplace insurance coverage and reporting procedures for students on unpaid work placements:
The Government of Ontario, through the MTCU, covers the costs of WSIB or private insurance (ACE-INA) for injuries or diseases incurred by students enrolled in an approved Ontario postsecondary program and participating in an unpaid work placement as required by their program of study. If the Placement Employer is compulsorily or voluntarily covered by the WSIB, a student injury/disease claim will be processed through the WSIB. For other Placement Employers, the claim will be processed through ACE-INA Insurers, a private insurance company retained by the Government of Ontario.
In 2013, the MTCU revised its guidelines and no longer requires the completion of the Work/ Education Placement Agreement (WEPA) Form in order for a student to be eligible for WSIB or private insurance coverage. The WEPA form has been replaced by the Postsecondary Student Unpaid Work Placement Workplace Insurance Claim Form which is only to be completed when submitting an insurance claim for an injury or disease incurred by the student during the placement. The Claim Form will be completed and signed by the Placement Employer, the Student and Humber. Humber will enter its MTCU-issued Firm Number in order to complete the Claim Form. The MTCU guidelines and the new Claim Form are posted on the MTCU ‘s website at: http://www.tcu.gov.on.ca/pepg/publications/placement.html.
In the event of a workplace injury or disease involving a Humber student on an unpaid work placement at the placement organization, the Placement Employer will immediately report the incident to Humber. A Placement Employer who is covered by the WSIB must follow all WSIB reporting procedures. In addition to completing the appropriate sections on the Claim Form, the Placement Employer will complete a Letter of Authorization that allows Humber to represent the Placement Employer on matters pertaining to the claim to WSIB. Humber will ensure that a WSIB Form 7 is completed within three days of learning of a work-related accident, and that it is submitted along with and the Claim Form and the Letter of Authorization to the WSIB.
For students returning to work after an illness or injury, the Placement Employer will work with Humber to review the Student Trainee’s restrictions and, where possible, modify the placement as required in order to accommodate the Student Trainee’s safe and timely return to the placement.
The Placement Employer will provide the Student Trainee with appropriate training and supervision to protect the Student Trainee from health and safety hazards that may be encountered at the placement organization.
Please be reminded that all eligible insurance costs for students on unpaid work placements will be covered by the Government of Ontario, through the MTCU, and not by the Placement Employer. The MTCU requires Humber to confirm whether the Placement Employer has WSIB coverage.
Please check one of the following; The Placement Employer:
Has WSIB coverage Does not have WSIB coverage
Declaration
By signature of an authorized representative hereunder, we confirm that we have read, understand and accept the terms listed in this document.
Name:__________________________________________Title_________________________________
Signature:_______________________________ Organization:_____________________Date:
Distribution
• Students must return the original signed letter to their Humber Placement Advisor.
• Copy to Placement Employer
IF YOU OR YOUR EMPLOYER HAS ANY QUESTIONS, PLEASE CONTACT
Linda Jin-Troendle, Program Co-ordinator Jean D’Souza, Business Placement Advisor
Phone: (416) 675.6622 ext. 3768 Phone: (416) 675 6622 ext. 72063
Faculty of Business, Lakeshore and IGS Campus Faculty of Business, Humber Lakeshore Campus
E-mail: linda.jin-troendle@humber.ca E-mail: jean.dsouza@humber.ca
IF YOU OR YOUR EMPLOYER HAS ANY QUESTIONS, PLEASE CONTACT
Susan Roberton, Program Co-ordinator Lidia Siino, Business Placement Advisor
Phone: (416) 675.6622 ext. 792223 Phone: (416) 675.6622 ext. 3708
Faculty of Business, Humber Lakeshore Campus Faculty of Business, Humber Lakeshore Campus
E-mail: susan.roberton@humber.ca E-mail: lidia.siino@humber.ca
IF YOU OR YOUR EMPLOYER HAS ANY QUESTIONS, PLEASE CONTACT
Linda Jin-Troendle, Program Co-ordinator Sheena Ordinario, Business Placement Advisor
Phone: (416) 675.6622 ext. 3768 Phone: (416) 675 6622 ext. 79210
Faculty of Business, Humber Lakeshore Campus Faculty of Business, Humber Lakeshore Campus
E-mail: linda.jin-troendle@humber.ca E-mail: sheena.ordinario@humber.ca
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