SECTION A: STUDENT INFORMATION & INTERNSHIP DETAILS. A1: Your Details

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1 Please read the following information carefully. INTERNSHIP PLACEMENT and RISK ASSESSMENT FORM For students undertaking an internship INSIDE AUSTRALIA as part of an approved internship subject for credit. The University of Melbourne is committed to ensuring the safety of all students. The student undertaking an internship shall complete and return this form to internship- at least 4 weeks before the internship commences. The student cannot be enrolled in an internship subject until this form is completed and returned. It is the responsibility of the student to ensure that he or she is enrolled in the correct internship subject in a timely manner, according to current academic census dates. Please remember that internship seminars, assessment pieces and internship/work placement are all hurdle requirements of the internship subject. Please refer to the relevant handbook entry. The content of this form will be used to complete the Professional Placement Letter Agreement which is the formal agreement between the Host Organisation and the University of Melbourne. Information collected on this form will be stored securely and only used or released in accordance with the University s privacy policy (refer to This document is divided into three sections: Section A: Student Information & Internship Details Section B: Metropolitan, Rural, Remote or Interstate Placements Risk Assessment Section C: Student Declaration SECTION A: STUDENT INFORMATION & INTERNSHIP DETAILS A1: Your Details Name: Student Number: Internship Subject: Course and Year Level: University Address: Contact Telephone: Emergency Contact Details Who can we contact in the event of an emergency? Name: Relationship to you: Contact telephone: address: Date: September 2014 Next Review: September 2016 AUSTRALIAN FORM Page: 1 of 11

2 A2: Details of internship/work placement Name of host organisation: Address/physical location of internship: Host supervisor name: Host supervisor s Position (eg manager): Host supervisor address: Anticipated Start Date: Anticipated Completion Date: Likely contact hours during internship (days or hours per week ): Nature of the work undertaken by organisation: Terms of reference/ activities to be undertaken while on placement, as agreed with your internship coordinator (please attach to this form if more space needed) A3: Maintaining communication with subject coordinator The site host supervisor will monitor your progress and will be your primary contact point if there are any concerns/ problems. The internship subject coordinator is responsible for monitoring your overall progress as well as responding to concerns raised during placement. You must provide regular progress reports to your internship subject coordinator. Please outline how you will maintain regular contact with the internship subject coordinator during your placement. I will keep in contact with the internship subject coordinator during seminars, via and/or telephone. SECTION B: METROPOLITAN, RURAL or INTERSTATE PLACEMENT RISK ASSESSMENT Please indicate your internship location: Melbourne metropolitan Outside metropolitan Melbourne Rural or regional area in Victoria Interstate It is important to consider the potential hazards for your placement. The five areas of risk which must be considered prior to undertaking an off- campus activity are: B1 Consider your fitness for travel and participation in the activity B2 Determine the safety of the method of travel to the site B3 Assess the risks of the location that you are travelling to B4 Assess the risks of the activity/tasks B5 Vaccinations Once completed, it is a good idea for you to keep a copy of this risk assessment with you while on placement for your reference. Contact your internship coordinator if you have any questions or concerns. Date: September 2014 Next Review: September 2016 AUSTRALIAN FORM Page: 2 of 11

3 B1: Consider your Fitness for Participation in the Activity It is recommended that you inform the University of any physical or medical conditions which may affect your comfort or safety or the safety of others during the activity or placement. Provision of this information is not mandatory, but is designed to assist in the event of an accident or emergency. Medical information shared with the University of Melbourne is subject to the Information Privacy Act 2000, Health Records Act 2001, Equal Opportunity Act 1995 and the University s Privacy Policy. More information about what you need to consider around disclosure of medical issues and placements: NOTE: The University reserves the right to deny participation in any of the activities where your physical or medical condition may affect your safe participation. Do you have any medical or physical condition which could affect your safe participation in the activity you are undertaking? If YES, please provide any relevant details which would be required in the event of an accident or emergency? Are you taking any medication that an ambulance or doctor should know about if you were to be incapacitated? If YES, please list the medication? Do you require a Q Fever Test or Vaccination? If YES, please provide details at section B5. YES YES YES NO NO NO Consent: I consent to this information being passed to the host organisation for the purposes of assessing the safety of my participation in this event. Name: Signature: Date: B2: Mode of Transport How will you travel to/from the site? It s important to consider the risks associated with all travel to/from or while undertaking your internship. Please outline your mode of transport, and the steps you will take to minimise risks associated with your travel. Mode of Transport (Circle) Car / Taxi/ Bicycle/ Public Transport/ Air / Other More information about the University s transport policies and other important safety guidelines Car travel Vehicle Use Policy Public Transport - Metlink s Travelling Safely Guidelines: public- transport/travelling- safely/ Bicycle safety rules and tips: and- road- rules/cyclist- safety Travel and Off- Campus Risk Management (UOM0330): Air travel: refer to the CASA Safe Flying Guidelines: Date: September 2014 Next Review: September 2016 AUSTRALIAN FORM Page: 3 of 11

4 Hazards for access to and from the placement location (select applicable) Driving: Will participants have to drive their own, rental or University vehicles to the site? Driving more than 2 hours: Will participants have to drive more than 2 hours to or from the destination? Will combined drivers drive more than 8 hours? Bicycle use: Are you aware of the local road rules and risks related to bicycle use? Public Transport: Is there a safety risk from taking public transport? Driving licence: If you are the driver, do you have a valid licence (international licence may be required)? Flying: Is it a high risk activity? Will participants be flying in aircraft with intentionally open doors? Are there issues of fatigue with arrival times or DFAT warning for the country or stop overs? Participants to find their own way: Is there a risk of participants getting lost? Should a map or coordinates be given to participants? Hiking: Are hikers inexperienced? Is there a risk of participants getting lost? Watercraft: Is there a risk of falling overboard? Are crew inexperienced? Does the driver need a licence? Other (Specify): How will you minimise the risk of travel? Mode of Examples of control measures (not a comprehensive list) Transport Car Always obey speed limits and traffic signals follow road rules and signed directions ensure that any medications taken do not interfere with driving capabilities do not pick up hitchhikers be familiar with the routes to be taken ensure that seat belts are worn by all passengers take rest breaks on long journeys do not drive under the influence of alcohol or drugs do not use mobile phones or other electronic devices while driving a vehicle check roadworthiness of vehicle Journeys longer than 5 continuous hours should have more than one driver per vehicle. Drivers should ensure that a 20 minute break is taken after 3 hours. Ensure you have a current drivers licence (international licence is require when travelling overseas) Bicycle Wear a helmet at all times while riding Comply with traffic signs and signals Use lights when riding at night Taxi Only take taxis that are clearly identified with official makings Note down taxi number. Agree to implement these control measures? Date: September 2014 Next Review: September 2016 AUSTRALIAN FORM Page: 4 of 11

5 Public Transport Waiting for a bus or train: plan your routes / know where you are going avoid isolated bus stops stand away from the curb until the bus arrives don t open your purse or wallet while boarding the bus have your money/pass already in hand at night, wait in well lit areas and near other people check timetables to avoid long waits Riding a bus or train: sit as close to the driver as possible stay awake and be aware of the people around you if someone bothers you or you see suspicious activity, change seats and tell the driver keep your belongings close by your side. check your purse/wallet if someone is jostling, crowding or pushing you. Air If you are travelling by Air, refer to the CASA Safe Flying Guidelines Consider the flight time (eg. fatigue) and arrival time at destination (eg. accessibility of onward transport) Consider the countries that you may have to stopover at (eg. DFAT warnings) Other (please specify) Please detail other possible hazards and control measures here B3: Location It is important to assess the risks of the location that you are travelling to. Hazards for location (select applicable): Remoteness: Is the site more than 5 minutes walk from a landline telephone AND out of mobile phone range? How far away are the closest emergency facilities? Weather/Outdoor work: Could participants suffer injury from exposure to weather (ie: sun or wind burn, frostbite)? Close proximity to roads: Will participants be required to conduct field work in close proximity to roads or moving vehicles? Flooding: Is there a threat of flooding in the area that could cause injury or hinder medical/rescue assistance? Security sensitive: Are there any security issues participants need to be aware of to avoid security risks or arrest by police? Cultural issues: Are there any cultural issues participants need to be aware of to avoid offending or being offended? Rough or steep terrain: Will participants be required to walk through rough terrain such as parkland, farmland State or National Park? Bushfire: Is there a threat of bushfire in the area? Check or other state Fire Authorities websites for warnings. Wildlife and other animals: Could participants be injured by wildlife or other animals? Security threat/emergency Situation: Is there any threat of physical harm or other threat to a participants personal safety? Facilities: Are there issues with inadequate personal facilities e.g. drinking water, tea rooms, toilets, wash up facilities? Natural disaster: Is there a threat of a natural disaster in the area that could cause injury or hinder medical/rescue assistance? Date: September 2014 Next Review: September 2016 AUSTRALIAN FORM Page: 5 of 11

6 Other (Please specify): How will you minimise the risks relating to your internship location? Location Risk Weather/ Outdoor work Bushfire, flood or natural disaster Remoteness Rough Terrain/ outdoors Cultural issues Close proximity to roads/noise/ other hazardous situations Security Threat/ Emergency situation Other (please specify) Examples of control measures (not a comprehensive list) use protective clothing, particularly covering the head. Head coverings should be wide brimmed hats rather than caps; wear sunglasses (UV protective safety glasses) for eye protection; use protective lotions on exposed parts of the body; arrange work patterns that maximize work in shady areas; avoid heavy work during the hottest part of the day; use personal water canteens; drink 250 ml of water every half- hour. Safety glasses are worn when performing activities which require them or have the potential to cause eye damage. Check with local Fire Authorities (i.e.: CFA) or land managers (i.e.: Parks Victoria or Dept of Sustainability & Environment) on local conditions and hazards regularly; Be familiar with emergency and first aid protocols of the host organisation Do not take unnecessary risk with your personal safety Ensure that you are familiar with all available communication tools in the remove or isolated location, eg. mobile phones, satellite phones, two- way radios etc. Wear sturdy footwear and long leg clothing; do not approach wildlife; be prepared for weather conditions; consider supplying sunscreen; carry sufficient drinking water where necessary; Be aware of possible cultural respect requirements of your fieldwork location and tasks Note your right to decline to participate in placement tasks and activities, and ability to discuss this with your academic supervisor Ensure that appropriate personal protective equipment is used (e.g. high visibility vest, hearing protection, protective clothing, safety glasses, hard hats) Follow the directions of your supervisor at the Host Organisation and/or other staff with designated OHS responsibilities (eg. first aiders, safety officers etc) Report all emergency situations by using the University s incident report form Please detail other possible hazards and control measures relevant to your internship here Agree to implement these control measures? Date: September 2014 Next Review: September 2016 AUSTRALIAN FORM Page: 6 of 11

7 B4: Placement and Task- Related Hazards Please consider the possible placement and task- related hazards associated with your internship. Refer to the relevant policies: Environmental Health and Safety Refer to the University s Manual Handling and Ergonomics Policy tasks/ I will be undertaking the following activities: Placement Work, learning or study undertaken by staff or students at a facility for the purposes of research or teaching for a set period of time. Site Visit Any closely supervised tour or day trip to a facility for study or research. Field Work (metropolitan) Work, study or research authorised by the University and conducted by staff or students at an off- campus site which is in a metropolitan or suburban location external to a building or structure, such as parks, gardens or roads. Remote Fieldwork Work or study undertaken at a site which is more than 5 km from a facility with phone or radio communication. Other Off Campus Activities Any University supervised or coordinated route, travel or excursion to an off campus location for the purposes of extracurricular activities. Hazards for placement and tasks (select applicable): Office Hazard/Facilities: Is there an Lifting or carrying heavy loads/manual handling: ergonomic hazard? Are there issues with inadequate personal facilities e.g. drinking Will participants have to lift or carry loads that could result in water, tea rooms, toilets, wash up facilities? muscle stress or strain? Repetitive physical tasks: Will participants have to complete repetitive physical tasks that could result in muscle stress or strain? Weather/Outdoor work: Could participants get suffer injury from exposure to weather (i.e.: sun or wind burn, frostbite)? Close proximity to roads: Will participants be required to conduct field work in close proximity to roads or moving vehicles? Cultural issues: Are there any cultural issues participants need to be aware of to avoid offending or being offended? Eye injury risk: Could tasks present an eye injury risk to participants? Hearing injury risk: Will participants need hearing protection during certain tasks? Mental stress: Could participants be intentionally exposed to situations that could cause fear, anxiety or other mental stress? Heights: Could participants fall from >1m causing injury? Chemicals: Could participants be exposed to dangerous types or quantities of chemicals causing injury or illness? Touring industrial facilities, workshops or laboratories: Are there local safety rules to comply with? Is an escort or induction for participants required? Biological Exposure: Is there a risk of exposure to biological material, this could include human/animal bodily fluids such as blood, saliva, waste? Graphic images: Could participants be exposed to graphic images or scenes (eg. medical procedures, live or on video)? Head strike injury risk: Could participants strike their head causing injury while working or observing? Discrimination: Are disabled participants prevented from accessing the location or tasks? Fumes: Could participants be exposed to dangerous types or quantities of fumes causing injury or illness? Operating equipment: Will participants operate equipment or machinery that could cause injury? Should licences be needed for any equipment? Date: September 2014 Next Review: September 2016 AUSTRALIAN FORM Page: 7 of 11

8 Bushwalking: Will participants be walking in park or open country alone or in small groups? Is there a risk of getting lost or injured? Boating: Will participants use water craft with a risk of falling overboard? Are licenses required to operate? Camping: Will participants be camping alone or in small groups? Is there a risk of getting lost or injured? Working with animals? Is there risk of injury to participant? 4WD / Off road: Will participants be required to drive off road or in 4WD conditions? Dusts: Could participants be exposed to dangerous types or quantities of dusts causing injury or illness? Sample Collection: Will participants be collecting samples? Is there a risk of injury whilst doing this? Other (please specify): How will you minimise the risks relating to your internship activities/tasks? Placement/ Task Risk Examples of control measures (not a comprehensive list) Agree to implement these control measures? Office Work Biological Exposure Mental stress/ Graphic images As far as reasonably practicable, ensure that your workstation is ergonomically set up using the University s guidance material on office ergonomics Utilise the Keyboard Workstation Assessment checklist to undertake a self- assessment of your workstation ssment_checklist.pdf Ensure training is received when exposed or handling biological material; Use suitable personal protective equipment such as eye protection, latex gloves, masks or gowns; Ensure universal health precautions are taken (e.g. wash hands and use disinfectants). Note your right to decline to participate in placement tasks and activities, and ability to discuss this with your academic supervisor. Bushwalking Operating Equipment Wear sturdy footwear and long leg clothing; do not approach wildlife; if in snake territory, stomp and make loud noises while walking; be prepared for weather conditions; consider supplying sunscreen; carry sufficient drinking water where necessary. Refer to the University s Manual Handling and Ergonomics Policy tasks/ Ensure that you have received on- the- job training in the correct use of mechanical plant, equipment or tools; Follow the safe operating procedures for the mechanical plant, equipment or tools; Utilise personal protective equipment while using the mechanical plant, equipment or tools as applicable (eg. gloves, eye protection etc); If you are unsure of any part of the task, discuss with your supervisor at the Host Organisation. Do not feel pressured to do something that you are uncomfortable doing. Date: September 2014 Next Review: September 2016 AUSTRALIAN FORM Page: 8 of 11

9 Manual Handling 4WD/Off road Farming activities Boating / activities around water Working with animals Other (please specify) Refer to the University s Manual Handling and Ergonomics Policy tasks/ Adopt correct manual handling techniques while undertaking physical work tasks; Assess the risk of undertaking the manual handling or physical work tasks; If you believe that you are not capable of undertaking the manual handling or physical work task, discuss with the supervisor at the Host Organisation. Do not feel pressured to do something that you are uncomfortable doing. ensure vehicle is roadworthy; Ensure you have a current drivers licence; Ensure you have adequate off road safety equipment, spare drinking water, communication devices in case of emergency. Wear sturdy footwear, long leg, long sleeve clothing and other personal protective equipment as directed; Ensure that you have received on- the- job training in the correct use of farm plant, equipment or tools; Be prepared for weather conditions; consider supplying sunscreen; Carry sufficient drinking water where necessary. Ensure sufficient life jackets and other mandated safety equipment and remind participants of basic safety behaviour around water; Use a Buddy System. Instruction & demonstration of safe animal handling technique; Supervision, assistance and direction during animal handling activities; First aid assistance and kits available; Appropriate protective clothing for activity. Please detail other possible hazards and control measures here. Note: All incidents must be reported immediately to the supervisor of the host organisation, and your internship coordinator notified. B5: Vaccinations Are vaccinations required? (Check with your Doctor if unsure) YES NO The University s Health Service: telephone or your doctor can provide further advice. Immunisation: Immunisations are designed to help protect you against harmful infections that can potentially cause serious complications including death. Immunisation works by using the body s natural defence mechanism, also known as the immune response, to build a resistance against specific diseases. The University health service can also assist in determining which vaccines you may require. Costs relating to immunization and supplies are the responsibility of the student. Have you discussed your internship location with your treating practitioner or YES the University Health Service at least 6 weeks prior to departure to ensure adequate vaccination coverage? Have you completed all routine background immunisations? YES Will you be working with animals? Have you reviewed the zoonotic health risks with your placement provider and health practitioner? YES Date: September 2014 Next Review: September 2016 AUSTRALIAN FORM Page: 9 of 11

10 Travel Safety Supplies A variety of supplies are available for purchase at the UoM health service including first aid kits, emergency trauma kits, water purifying solution, insect repellent containing DEET, mosquito nets and malarial prophylactic medication. The UoM health service also supplies a small range of medications to assist with diarrhoea and vomiting whilst traveling. More information available at: I have identified that the following travel supplies are required to reduce the risk associated with my travel. Details: YES I have purchased the above travel supplies or will do so prior to my departure. YES NOTE: Students undertaking an approved Faculty internship outside of metropolitan Melbourne are automatically covered by the University's Personal Accident, Public Liability and Professional Indemnity insurance policies whilst they are participating in, and travelling directly to, or from, relevant and authorised Work Experience / Field / Outside Placements. Cover is provided for all students when undertaking University approved travel in connection with the student's studies (e.g. conferences, field work, outside placements, research), regardless of how the travel is actually funded. SECTION C: STUDENT DECLARATION Prior to undertaking activities off campus for an internship placement I will ensure that I have: 1. Enrolled, completed all course requirements, and with enough points left in my degree/subject loading to undertake the internship placement. 2. An understanding of the skills and standards required. 3. Advised my internship coordinator if I am under the age of 18 years. 4. Provided Emergency Contact Details to the University where requested. In undertaking the placement, I understand that I have duties and responsibilities to abide by the policies and procedures of the University. I shall be responsible for: the reasonable care for my own health and safety and that of other personnel who may be affected by my conduct; cooperating with others in relation to actions taken by the Host Organisation and University to comply with Environmental Health and Safety legislation; not willfully placing at risk the health or safety of any personnel; not willfully or recklessly interfering or misusing anything provided in the interest of health and safety or welfare of any personnel; undertaking tasks in accordance with relevant standard operating procedures or work instructions; wearing correct personal protective equipment specified in standard operating procedures or working instructions; seeking supervision and guidance from the relevant supervisor for all new or modified work procedures; using the Host Organisation and University procedures to report hazards and incidents; where required, participating in health and safety consultative arrangements, including meetings; where required, participating in health and safety information, training and induction procedures; following the Host Organisation and University procedures for emergencies. Date: September 2014 Next Review: September 2016 AUSTRALIAN FORM Page: 10 of 11

11 In undertaking the placement I agree to the following: 1. If interviews (such as client/research/project interviews) are required to be conducted for the purposes of fulfilling the placement all information imparted is to be used only for that task and will not be released or allowed to be used in any other manner. 2. Immediately upon the information no longer being required for my course requirements (i.e. once I have completed the placement and assessment) I will destroy all notes and data in my possession which may identify any individual interviewed during the placement unless these are to be held in confidentiality by the host. 3. I will conduct myself in such a manner that is respectful and courteous to the placement entity. 4. I will advise my internship coordinator of any changes to my participation in the internship placement, and recognise that it is my responsibility to ensure I have completed all subject and course requirements associated with this internship placement. 5. For overseas internship placements, in the event that DFAT travel advice for the location changes to reconsider your need to travel or do not travel, I acknowledge that I may be required by the University of Melbourne to leave the area/country immediately, and must comply with any such request. I understand that all medical information shared with the University of Melbourne (the University) will be treated confidentially and is subject to the Information Privacy Act 2000 (Vic) or Health Records Act 2001 (Vic). It is recommended that I inform the University of any physical or medical conditions which may affect my comfort or safety or the safety of others during the activity or placement. I reserve the right to decline to attend the placement or research program for any reason, or to leave the host location at any time if I feel that my personal safety or wellbeing is at risk. I also understand that the University reserves the right to exclude any student from participation in the placement or research program for reasons which the University believes are justified. If I have any other concerns, discomfort or uncertainty relating to the placement or research program at any time, I will contact my University academic supervisor as soon as possible. I accept the above terms and conditions and understand the information I have been given. Student Name: Signature: Date: Approved by the relevant University of Melbourne Internship Coordinator Name: Signature: Date: SEEK ADVICE FROM FACULTY EHS COORDINATOR? YES Date: September 2014 Next Review: September 2016 AUSTRALIAN FORM Page: 11 of 11