Student Declaration of Understanding and Agreement

Workplace Safety and Insurance Board or Private Insurance Coverage For Students on Program-Related Unpaid Placements

Student coverage while on unpaid placement: Note: Prior to the start of the unpaid placement, this Agreement must be completed AND submitted online by the student to indicate the Student Trainee’s acceptance of the unpaid work placement conditions.

The Ontario Ministry of Colleges and Universities provides Workplace Safety and Insurance Board (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.

• The Ministry provides private insurance for Student Trainees and limited coverage for placements outside of Ontario (international or other Canadian jurisdictions).

• Carleton University has also arranged for private insurance coverage for students who attend placement opportunities that are not covered under either the WSIB or the Ministry’s private insurance.

• Students are advised to maintain insurance for extended health care benefits through the CUSA/GSA Student Health & Dental Plan or other group or private personal insurance plan. (http://carleton.ca/health/insurance/)

Please be advised that in the event of a workplace injury or disease where a claim is being made,Carleton University will be required to disclose personal information relating to the unpaid work placement and any WSIB claim or claim made through the Ministry’s private insurer.

Student Name and Carleton Student number*
First Last Student Number
Name of Parent/Legal Guardian (for students less than 18 years of age)
First Last
Visa Student*
YES
NO
Organization's Name*

Estimated Number of 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).
Declaration and Agreement*
I agree to the following (in lieu of signature)
I hereby declare that I have read and understand that WSIB or private insurance coverage will be provided through the Ministry or by Carleton University while I am on an unpaid placement.

I agree that, over the course of my placement, I will participate in, comply with all safety-related training and procedures provided by the Placement Employer.

I agree that I will promptly inform my Placement Employer of any safety concerns. If these concerns are not resolved, I will contact my Departmental Co-ordinator at Carleton University and notify them of any unresolved safety concerns.

I agree and understand that all workplace accidents sustained while participating in an unpaid work placement must be immediately reported to the Placement Employer and department of Risk and Insurance at Carleton University at Risk@Carleton.ca

I also agree and understand that a Ministry Post-Secondary Student Unpaid Work Placement Insurance Claim form (https://www.forms.ssb.gov.on.ca/mbs/ssb/forms/ssbforms.nsf/FormDetail?OpenForm&ACT=RDR&TAB=PROFILE&SRCH=&ENV=WWE&TIT=1352&NO=022-13-1352E) must be completed and signed in the event of any workplace injury and submitted to the department of Risk and Insurance at Carleton University at Risk@Carleton.ca

In the event of an injury, I also agree to maintain regular contact with the department of Risk and Insurance at Carleton University at Risk@Carleton.ca and the departmental co-ordinator to provide all information relating to any restrictions and my ability to return to the placement.

I understand the implications and consequences of consenting to this this agreement.
Date
MM slash DD slash YYYY

Name
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