Get Work Approval Form

STATE OF NEW HAMPSHIRE DEPARTMENT OF LABOR PO BOX 2076 CONCORD NH 03302-2076 603 271-3176 APPROVAL FORM FOR NON-PAID WORK-BASED ACTIVITIES UNDER RSA 279 22-aa Please type or print all information School/institution/Organization Secondary Post-secondary Other Address Street Town/City State Zip Code FAX If disabled check one VR AA CMHC Provider Agency Program Name FAX Contact Person Title Tel. Type of Placement check one Job Shadow Clinical Work Experience Internship Service Learning Mentor Program Situational Assessment Training Program Other Career Interest/Objective Is academic credit given for this program Yes No Hours per student/learner Days per week Total number of days at business site. Supervision Please describe how the student s /learner s will be supervised and by whom 1. Does each place of business have a safety program Yes No Explain 2. Is there any hazardous equipment involved Yes No Type 3. Has all Safety Training been completed as applicable to each site Including specific training for equipment as noted above. Yes No Explain The information above as provided is accurate and we guarantee that this placement in no way establishes an employee/employer relationship between the student s /learner s and the business site at which they are placed* Attach list of business es participating in this placement. Must include Name of business address phone contact person* Notify the DOL of any additions to this list. Also attach a sample copy of Agreement or Contract for this placement. Authorized Signature Title For D. Supervision Please describe how the student s /learner s will be supervised and by whom 1. Does each place of business have a safety program Yes No Explain 2. Is there any hazardous equipment involved Yes No Type 3. Has all Safety Training been completed as applicable to each site Including specific training for equipment as noted above. Is there any hazardous equipment involved Yes No Type 3. Has all Safety Training been completed as applicable to each site Including specific training for equipment as noted above. Yes No Explain The information above as provided is accurate and we guarantee that this placement in no way establishes an employee/employer relationship between the student s /learner s and the business site at which they are placed* Attach list of business es participating in this placement. Yes No Explain The information above as provided is accurate and we guarantee that this placement in no way establishes an employee/employer relationship between the student s /learner s and the business site at which they are placed* Attach list of business es participating in this placement. Must include Name of business address phone contact person* Notify the DOL of any additions to this list. Must include Name of business address phone contact person* Notify the DOL of any additions to this list. Also attach a sample copy of Agreement or Contract for this placement. Authorized Signature Title For D. Supervision Please describe how the student s /learner s will be supervised and by whom 1. Does each place of business have a safety program Yes No Explain 2. Is there any hazardous equipment involved Yes No Type 3. Has all Safety Training been completed as applicable to each site Including specific training for equipment as noted above. Yes No Explain The information above as provided is accurate and we guarantee that this placement in no way establishes an employee/employer relationship between the student s /learner s and the business site at which they are placed* Attach list of business es participating in this placement.