Workplace supervisor ACM40418

Workplace Supervisor and Facility Checklist

ACM40118 Certificate IV in Veterinary Nursing

To successfully complete the practical component of this course students need to undertake weekly work placement throughout their course to a minimum of 480 hours work placement in an appropriate workplace under the supervision of qualified and experienced supervisor. Note: this course is companion animal based, you might be requested to provide additional evidence if undertaking placement with equine or large animals.

This form provides TAFE specific information about the resources, facilities and supervisor at the proposed workplace. We may seek further clarification from you before approving the work placement and the student's enrolment.

Some units in the course require students to demonstrate skills with several different types of animals or use specific equipment. If the workplace only has one species or cannot cover all the tasks in the unit, the student may be required to do further work placement at another facility. They will need to take video of themselves in the workplace completing a range of animal care tasks for their practical assessments.

You can download the Host workplace and supervisor guide here which will give you more information about hosting a student.

SECTION A: Student and Workplace Details

Student Firstname

Student Lastname

Student Email

Workplace Name

Workplace address: Street

Workplace address: Suburb

Workplace address; State & Postcode

Workplace Email

Brief description of the workplace

If the student is currently employed at this workplace:

How long has the student been employed? Years / Months

What is the student's current position title?

How many hours does the student work each week?

SECTION B: Supervisor Details

Supervisor First Name:

Supervisor Last Name:

Position Title:

How long have you been in this position?

Phone Number:

Supervisor Email for Student/Course Communication:

Best days/time to contact:

Supervisor Requirements

Qualifications - Certificate IV in Veterinary Nursing or higher.

Provide details of your qualification(s), year and where it was gained:

Experience - Minimum of two years' experience post graduation as veterinary nurse or veterinarian.

Provide details of your work experience:

Desirable: Experience as a workplace supervisor.

Have you been a workplace supervisor before?

SECTION C: Workplace Resources Checklist

This section outlines the facility equipment and resource requirements the student needs access to in the workplace to successfully complete their practical assessment tasks.

Will the student have access to the following resources in the workplace? Please see the Work placement guide for host employers and supervisors for the full list of equipment in each category.

**SECTION C: Workplace Resources Checklist**
This section outlines the facility equipment and resource requirements the student needs access to in the workplace to successfully complete their practical assessment tasks.
Will the student have access to the following resources in the workplace? Please see the Work placement guide for host employers and supervisors for the full list of equipment in each category.
Office and Pharmacy
	Yes	No
Office equipment and resources including practice management software	Yes	No
Veterinary pharmaceuticals and equipment to prepare formulations	Yes	No
General Animal Care equipment and resources for;
Personal protective equipment	Yes	No
Cleaning and disinfecting work areas, surfaces, cages and surgical instruments and equipment	Yes	No
	Yes	No
Suspected Infection Disease Control	Yes	No
General animal care: holding cages and bedding feeding equipment scales and general treatment equipment	Yes	No
	Yes	No
Equipment and resources for;
Bandaging	Yes	No
Injections	Yes	No
	Yes	No
Surgical preparation	Yes	No
Surgery	Yes	No
Intravenous fluid administration	Yes	No
Anaesthesia	Yes	No
Imaging incl. X-Rays and either ultrasound or endoscope	Yes	No
Pathology inc. collection, internal and external testing	Yes	No
	Yes	No
Dental procedures incl. prophylaxis, assisting with simple extractions and x-rays	Yes	No

SECTION D: Permission to collect documentation, film videos and/or record audio and/or take photos in the workplace

As part of the assessment evidence for the Certificate IV in Veterinary Nursing, the student is required to collect documentation, and/or film videos, and/or record audio, and/or take photos during work placement. These materials are required for the assessments. The student is also required to complete a training logbook.
These materials could involve the student, staff members of the workplace, clients, clients’ animals, and other relevant people involved in the activities of the workplace.

In some cases a TAFE NSW assessor may be available to come to the workplace and directly observe the student's practical skills.
Please note:
These materials will only be used for the purposes of assessment in the Certificate IV in Veterinary Nursing at TAFE NSW.
The student is required to maintain confidentiality of the workplace and client details as provided in Student Code of Conduct. The student will retain these materials for study purposes only.
TAFE NSW will retain these materials for audit purposes only.

I give permission for the student named on this form to gather workplace evidence for the purpose of assessment
Please contact me to discuss this requirement

SECTION E: WHS risk assessment

**SECTION E: WHS risk assessment**
Work health and safety management
	Yes	No
Does your workplace have a work health and safety management system or processes in place to satisfy its duty to ensure the health and safety of workers and other persons at your workplace?	Yes	No
Is an emergency plan in place and are staff advised of what to do in an emergency such as evacuation?	Yes	No
Induction and training
Will the student be given a WHS induction on commencement in the workplace? The induction should include: Emergency Response Plan First Aid procedures for the workplace Reporting accidents/incidents Identified Hazards and controls Universal Precautions: Psychological, e.g. violent or abusive clients, challenging behaviour, security, personal safety Manual Handling	Yes	No
Will the student be trained in safe work practices during their work placement?	Yes	No

Please list risks to the student:

Please list risks to the student:
	Risk level			How will these be controlled?


	Low	Medium	High	if Medium or High
Handling animals eg bites, scratches
Zoonosis eg toxoplasmosis
Chemical exposure, eg toxic drugs or cleaning products
Use of particular equipment
Manual handling eg lifting animals or equipment
Needlestick or sharps injuries
Radiation exposure eg imaging equipment
Psychological eg exposure to abusive clients, confronting surgical procedures
Other:
Other:

Please list any tasks/activities the student is not to undertake, such as no-go areas, machinery or equipment that is too dangerous for new or young workers to operate:

WHS risks have been assessed and managed in conformity with the Work Health and Safety Act 2011 (NSW) Note: you will be sent a WHS Induction Form via Adobe Sign to complete on their first day of placement.

I confirm that the activities the student will undertake are suitable for the student

I confirm that the information provided on this form is correct.

Date: 27 Jul 2025

Sign Here

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