SAMPLE
Cooperative Education-Child Labor Law Hazardous Occupation Form

		
LAST NAME                                     FIRST NAME                             MI	SOCIAL SECURITY NUMBER	DATE OF BIRTH	

	
EMPLOYER NAME	EMPLOYER ADDRESS	

FOR_____DAYS PER WEEK______HOURS PER DAY	
BETWEEN THE HOURS OF ____A.M._____P.M.	

SCHOOL	TRAINING PROGRAM	
Check the hazardous occupation(s) for which the exemption applies:
•	On any scaffolding, roof, superstructure, residential or nonresidential building construction, or ladder above six (6) feet
•	In the operation of power-driven woodworking machines
•	In the operation of power-driven metal forming, punching, or shearing machines
•	Slaughtering, meat packing, processing, or rendering except as provided in 29 C.F.R. part 570.61(c) which includes meat slicing machines.
•	In the operation of power-driven paper products and printing machines
•	Excavation operations which include the operation of trenchers and earthmoving equipment
•	Working on electric apparatus or wiring
•	Operating or assisting to operate: (including starting, stopping, connecting or disconnecting, feeding, or any other activity involving physical contact associated with operating) a tractor over 20 PTO horsepower,  any harvesting, planting, or plowing machinery.
•	Fork Lift (Only in an agricultural setting or with non-FLSA covered employers)
Note: The USDOL does not allow an exception for student learners in Hazardous Occupation #7, which covers the operation of power-driven hoisting apparatus in non-agricultural employment.  Other equipment not permitted includes derricks, hoists, and cranes.  Employers may contact the USDOL at 1.866.487.2365 to verify their coverage under the FLSA (Fair Labor Standards Act). OSHA also requires all fork lift operators to have completed an OSHA approved training course prior to working.
In accordance with Section 450.061(2) F.S., the undersigned attests to the following:
•	That the student learner is enrolled in a youth vocational training program under a recognized state or local educational authority.
•	That the work of the student learner in the occupation declared particularly hazardous is incidental to the training received.
•	That the work performed shall be intermittent and for short periods of time and under the direct and close supervision of a qualified and experienced person.
•	That the safety instructions shall be given by the school and correlated by the employer with on-the-job training.
•	That the student has a schedule of organized and progressive work processes to perform on the job.

_______________________________	             	 _________________________________________________
Print or Type Student's Name			Student's Signature	         		Date                

_______________________________		_________________________________________________
Print or Type Parent/Guardian's Name		Parent/Guardian's Signature              	 Date

_______________________________	       	_________________________________________________
Print or Type Employer's Name			Employer's Signature	  		Date

________________________________               	_________________________________________________
Print or Type Teacher/Coordinator's Name		Teacher/Coordinator's Signature		Date

________________________________		_________________________________________________
Print or Type Principal's Name			Principal's Signature			Date