As part of their educational experience, students have opportunities for experiential learning within community settings. These may include – but are not limited to – practicums, course-based projects, and service learning. Carleton University wants to ensure that our students have a safe and enjoyable experience while participating in unpaid placements.

There are several requirements that students must complete before they may begin their experiential learning experience. These may include – but are not limited to – screening and vaccinations, mandatory trainings, and the completion of a formal Police Record Check. Most, if not all of these, require the handling of students’ personal information.

Freedom of Information and Protection of Privacy

The university is responsible for the security of students’ personal information under the Freedom of Information and Protection of Privacy Act (FIPPA). It is important that our practices in dealing with students are in line with the requirements of the Act. To protect the personal information of students, the Student Attestation Form was created.

Purpose of the Student Attestation Form

The Centre for Community Engagement, in collaboration with the Office of Risk Management; Legal Counsel; General Counsel; Environmental Health and Safety; and Health and Counselling developed a form where:

  1. Placement requirements are communicated clearly to students by Carleton University and the community organization.
  2. Students attest to the completion of their placement requirements.

With the development of this tool, Carleton staff and faculty members will not encounter student personal information as it relates to student placement experiences.

Using the Template

Instructions on using the form are listed below:

  1. Representatives from Carleton University and the placement organization work together to ensure all placement requirements are indicated in the Student Attestation Form.
  2. Once all requirements are clearly listed, the form is delivered via email to the student for completion.
  3. The student works to complete all listed requirements.
  4. Once all requirements are executed by the student, the student completes and signs the form.
  5. Once signed, the form is returned to Carleton University for review and signature.
  6. Carleton University then informs the placement organization of the student’s completion of all placement requirements.
  7. Carleton University then sends a copy of the completed form to the placement organization for review and approval.

If there are any issues (e.g., the student cannot complete one or more of the listed requirements) they must inform Carleton and the placement organization immediately.

Student Attestation Form

Agreement Signatures

The completion of this form may require the signature of other individuals, such as the student’s primary care (family) physician, in addition to Carleton University and the placement organization.


Should you have any questions regarding the Student Attestation Form and its use, please email