Work Experience Supplementary Application Form

This form is to be completed for students with any personal or educational special/additional needs/circumstances.
Please ensure all sections are completed. This information helps us to place the student with the right employer, we do
not disclose the information without previous discussion with you. The information is purely to assist us when placing.

Once the student is placed a member of school staff MUST call the employer to discuss the contents of the form.

Student & Education Details

Student Name

School Year Group

School Contact Role

Name
School/College School
Telephone No Contact
Email
Is the student currently attending school?

What was their attendance last term (percentage)?

What education will the student receive in addition to

the placement?

Work Experience Arrangements

Is the student able to undertake work

experience independently?

If not who will accompany the student?

Name Role in
School
Is the student able to work a full 7 hour day?

If not what pattern would be appropriate?

Monitoring & Support for Extended Placements

Who within school will monitor the placement?

Name Position
The student should be visited at the placement within the first 2 weeks and a phone call/visit every 4 weeks
thereafter, more/less depending on the needs of the student.
The EBP will maintain contact with the employer on a half termly basis.
Is the student involved with any other agencies?
 Student Profile & Risk
Please indicate the student’s reading age and
language skills
Please indicate the student’s numeracy age
and number skills
Will the student be able to read and understand health and safety instructions that are
Written? Yes / No Verbal? Yes / No

Please outline below the nature of the students personal, additional or educational special needs. Non SEN
issues may include difficulty accepting authority, problems relating to peer group, extreme shyness/anxiety,
needing a high level of supervision, having been bullied etc.
Special Need: What form does it take and how How might this affect the young
severe is it? person in the workplace?

Please indicate below if there are any risk factors e.g. violence, drugs, theft, that affect the young person

Risk Factor: How might this affect the young What strategies are in place to
person in the work place? reduce the risk?

Thank you for taking the time to complete this form.

Signed: Date:

On behalf of the School

By signing this you are confirming you have read, understood and agreed to how we are going to use and store the
student’s personal information.

How information about the student will be used - Members of the EBP work experience team will use the information
that has been provided to make informed choices about which companies may be suitable for the work placement.

How long we will keep information about the student - We will keep the information until the student is 25 years old,
which is a legal requirement.

Who we will share the student information with - We will share the student name, year group and school name with the
work provider where the work experience placement is carried out. This is so that the employer can prepare for the work
placement.

If you need any further information - Please email us at info@ebpwb.co.uk or to view our privacy policy, please visit our
website http://educationbusinesspartnership.co.uk/privacy-policy/