This Is to Be Completed Collaboratively by Student and Faculty Sponsor and Signed Off

This is to be completed collaboratively by student and faculty sponsor and signed off by the Head of Department for Nursing BEFORE student leaves UK

Elective title : Croatia Elective Experience / Faculty Sponsor
Print
Sign / Executive Dean
Print
Sign
Student name:*
Term time contact details: * / Student number: *
Cohort and Branch: *
Date of Assessment: N/A / Date leave UK: *
Date return UK: *
Date elective from: 11th May 2015
Date elective to: 22nd May 2015
Elective venue name and address:
Centre for Autism Zagreb:
Dvorniciceva 6
10 0000 Zagreb
Croatia
Slobostina Special School, Zagreb
Nikole Andrića 3
HR-10020
ZAGREB / Accommodation address during elective inc phone:
Ravinice Youth Hostel
I Ravnice 38d,
10000, Zagreb,
Croatia
Phone:+385 1 2332 325
And
Slobostina Special School, Zagreb
Nikole Andrića 3
HR-10020 ZAGREB
Tel: 01/6640-166 / Have you had contact with your host organisation?
Yes: Via Nick Preddy
Have they confirmed your placement arrangements? Yes: Via Nick Preddy
Name and contact details of emergency contact while you are outside UK. This person should have copies of your passport and travel documents * / Name and contact details of host supervisor:
Contact via Nick preddy.
or +44 7916 941322 / Have you registered with LOCATE?
http://www.fco.gov.uk/en/travel-and-living-abroad/staying-safe/Locate/
Y/N
Have you checked the current foreign office safety advice for the country you are visiting?
http://www.fco.gov.uk/en/travel-and-living-abroad/travel-advice-by-country/
Y/N / Has a member of UWE staff visited the host organistion and location of the placement
Yes.
Risk factors
These are a guide and should be expanded and added to. / Control measures
Examples. These are a guide and should be expanded and added to. / Risk level
low/medium/high / Additional control measures / actions / By who student/staff
Work placement / Suitable local health and safety induction. Suitable safety equipment provided / Low / ·  Placement is in a group with other students
·  Placement is supervised by two Academics from UWE
·  All arrangements are made by UWE academic
·  Each placement area has an identified lead person who works with UWE staff and student to manage any risks / Shared responsibility
Travel
Are you aware of any important cultural issues
Suitable funds, correct currency, visas / Research into country culture Suitable clothing for modesty / Low / ·  Pre-placement meetings with student group helps identify cultural issues
·  Students advised to research / Nick Preddy/Dorenda Mackie
Students
Accommodation / Booked and have all details / Low / ·  Accommodation is booked and supervised by academics
·  Specialist Diets are not particularly catered for in placement and accommodation areas, so students are advised of typical food and diet in Croatia / Nick Preddy/Dorenda Mackie
Health and Environment
Specific medical risks
Sanitation / Have you got the correct immunisations *
Students to enter any specific health or disability issues here, or discuss privately with Nick Preddy or Dorenda Mackie if they wish to disclose. / Low / ·  None needed
·  Students are advised to manage their own medications, if relevant
·  Students advised to disclose any health or disability issues that could impact upon the placement experience in the same way they are advised to do so for university place. This is not mandatory / Student responsibility
Relevant documentation / Personal indemnity and travel insurance, correct visas letter of appoint from host organisation. Please attach copies. / Low / ·  Visa not required
·  Other documentation obtained by student and monitored by admin staff at UWE and academics / Student/Admin staff/Academic
Individual student factors
E.g. female students in some countries
Lone working / Research into country culture etc / Low / ·  Pre-placement meetings with student group helps identify cultural issues / Student/Academics
RISK LEVEL / ACTION LEVEL
Low
Medium
High / Unlikely to happen minor consequences - Acceptable
Likely to happen moderate consequences -Tolerable
Likely to happen serious consequences - Intolerable / No action necessary
Some further measures may be required
Immediate action – cease the activity or do not start further control measures essential (to achieve medium or low.)
I understand that the University of the West of England cannot be held responsible for my safety while I undertake my overseas placement.
*
Signed……………………………………………. Print……………………………………………….. Date: