Letter from Placement Employer

Process for Workplace Insurance for Post-Secondary Students on Unpaid Work Placements

Workplace Insurance Context:
• The Ontario Ministry of Colleges and Universities provides WSIB coverage for Student Trainees enrolled in an approved program at Carleton University and participating in unpaid work placements with employers who have WSIB coverage.
• For placement employers without WSIB coverage, the Ministry provides private insurance for Student Trainees.
• Carleton University has also arranged for private insurance coverage for students who attend placement opportunities that are not covered under either WSIB or Ministry’s private insurance plan. For any questions regarding this form, please contact the department of Risk and Insurance at Carleton University at Risk@Carleton.ca
Documentation Process:
• Placement Employers must electronically file the form below with the student's department (ICSLAC) prior to the commencement of the unpaid work/education placement.
• An email copy will be sent to the placement employer, who must keep it on file.

Student Name and Carleton Student number*
First Last Student Number
Please reach out directly to the student for their Carleton student #.
Organization's Name*
Supervisor's Name and Email Contact Information*
First Last Email information
Estimated Number Placement Hours*
- 144 as requirement for either CURA 5011 or CURA 5012
- 288 hours as requirement for both CURA 5011 and CURA 5012
This placement applies to Graduate students registered in the Graduate Diploma in Curatorial Studies (Institute for Comparative Studies in Literature, Art and Culture, Carleton University) as part of their practicum course requirements. Please indicate whether the estimated number of hours covers a single course (either CURA 5011 or CURA 5012) or both (CURA 5011 and CURA 5012, taken consecutively over two academic terms).
The employer's organization is covered under the Workplace Safety & Insurance Board.*
- YES
- NO
Declaration*
I agree to the following (in lieu of signature)
By checking the box above in lieu of signature of an authorized representative, the Placement Employer hereby agrees to the following:
That it will immediately report to the department of Risk and Insurance at Carleton University at Risk@Carleton.ca or 613-520-2600 and the departmental co-ordinator any workplace injury or disease involving a student on an unpaid work placement and:
• Where the Placement Employer is covered by the WSIB, the Placement Employer will comply with all WSIB reporting procedures.
• If the Placement Employer is not covered by the WSIB, then it will comply with the Ministry’s private insurer’s reporting procedures found in the Ministry’s “Guidelines for Workplace Insurance for Post-Secondary Students of Publicly Assisted Institutions on Unpaid Work Placements” at: http://www.tcu.gov.on.ca/pepg/publications/placement.html
• When the Placement Employer is covered under the Workplace Safety and Insurance Act, a Form 7 and a Letter of Authorization to Represent the Placement Employer will be completed and submitted to Robin Karuna, WSIB Program Administrator at Carleton University at Robin.Karuna@Carleton.ca within three days of learning of a work-related accident.
The Placement Employer agrees that it will provide the Student Trainee with health and safety training and take appropriate precautions to ensure that the Student Trainee is supervised in order to protect the Student Trainee from health and safety hazards that may be encountered at the placement organization, as required under the Occupational Health and Safety Act.
In the event of a claim, the Placement Employer agrees that it will review the Student Trainee’s restrictions and,where possible, modify the program as required in order to accommodate the Student Trainee to facilitate return to the program.
Phone
This field is for validation purposes and should be left unchanged.

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