St Luke’s Science and Sports College
A Church of England (VC) School founded in 1873
Harts Lane
Exeter
EX1 3RD
Tel: 01392 204600
e-mail: office@st-lukes.devon.sch.uk
Principal: Dave Holt
WORK EXPERIENCE RISK ASSESSMENT FORM
Name of Student: _________________ Date of Birth: _________ Tutor Group: _____
To the Parent/Guardian
Does your daughter/son have a health problem in any of the following areas which would affect them
doing their work experience placement? (Please tick)

Restriction for normal physical activity or games

Skin allergies, eczema, other allergies (e.g. Nuts)

Bronchitis, asthma, chest complaints

Hearing problems

Heart Disease that affects their ability to do physical tasks

Diabetes

Significant colour defect or other visual problems

Learning disability which my cause them not to understand instructions

Any other health problems (including the need for regular medication) (if ticked, please give
details)………………………………………………………..….……………………………………

There are no health reasons affecting my daughter’s/son’s ability to take this placement
My signature also confirms my consent to my son/daughter taking part in the work experience
program. I understand that I will be notified of my child’s placement by him/her bringing home a
completed Employer’s Confirmation Form. Should I have any concerns regarding the placement, I
will contact the school.
SIGNED………………………………………………………. DATE …………………………
Please return this form in its entirety, do not detach this bottom part
To the employer: This student is below compulsory school leaving age.
Parents and students need to know what measures are in place to control significant risks associated with
the placement before it begins. You are not obliged to provide this information in writing; it could be passed
on at a visit to your premises by the student for conveyance to his/her parent/guardian before they come on
placement. You may find it convenient, however, to pass written information on to the school who will
distribute it to the students and the parent/guardian.
Please complete and sign one of the options below:-
 Option 1 There are no significant risks associated with this placement for this young person.
 Option 2 The student will be told of significant risks and control measure at a pre-placement visit
 Option 3 Please complete the following table:-
Significant Risk
Measure in place to control
SIGNED………………………………………..………………………………. DATE ………………………………..