Application for Work Experience or Observation Placement

If completing by hand, please use black ink. Information will be treated in the strictest confidence.
Please Note: You need to be in Year 11 or above to apply for Work Experience at UHDB.

Personal Details
Surname/Family Name

First Names

Title

Date of Birth Age

Address for

correspondence

Postcode Telephone No.

Name of Emergency Emergency

Contact
Contact Tel No

E-mail Address

College/School/University
Name and subjects
studied

Tutor’s name Tutor’s Tel No

Date wanting to start Length of Work

Work Experience Experience required

Area/Department required

Please indicate which Royal Derby Queens Hospital Sir Robert Peel Samuel Johnson Florence
Burton Tamworth Community Nightingale
hospital you would like Hospital Community
your placement at: Lichfield Hospital

☐ ☐ ☐ ☐ ☐

Other Relevant Information

Please use the space below to provide information to support your application and tell us why
you wish to undertake work experience in your chosen area. (Continue on a separate sheet if
necessary.)

Previous Work Experience or Employment

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Application for Work Experience or Observation Placement

Please give details of any previous Dates to/from Details of Job held
paid or voluntary work you have had.

Model Declaration

1. Are you currently bound over or do you have any current ‘unspent’ Yes ☐ / No ☐
(recent) convictions that have been issued by a Court or Court-Martial in
the United Kingdom or in any other country?

2. Have you been charged with any offence in the United Kingdom or in any Yes ☐ / No ☐
other country that has not yet been disposed of?

If you have answered yes to any of the above, please provide further details below:

Student, Parent and Teacher Agreement to Trust requirements

 The Trust places considerable importance on the need for attention to Health and Safety at
work. You have the responsibility to acquaint yourself with the safety rules of the work place,
to follow these rules and make use of facilities and equipment provided for your safety. It is
essential that all accidents, however minor, are reported.

 The Trust will also expect you to observe other rules and regulations governing the workplace
which are drawn to your attention. Please note that there is a No Smoking Policy covering
the whole working environment and that there are securtiy arrangements applicable to most
locations.

 The Trust fully supports equal opportunities in employment and opposes all forms of unlawful
or unfair discrimination on the grounds of ethnic origins, gender, disability, age, religion or
sexuality.

 There will normally be no payment for meals or travelling expenses.

 Please note that during the placement, you may be exposed to Covid-19. We encourage you
to maintain a full Covid-19 vaccination to protect yourself, our staff and our patients.

I have read and understood the above requirements.

Signed (Applicant): Date: _____________

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Application for Work Experience or Observation Placement

PLEASE OBTAIN THE FOLLOWING SIGNATURES - IF UNDER 18YRS:

Parent/Guardian
 I have read the work experience information and understood the requirements. I will ensure
the candidate carries out these obligations and confirm that he/she is not suffering from any
complaint, which might create a hazard to them or to others working with them. I give
permission for my son/daughter to attend the placement and observe during his/her visit to
University Hospitals of Derby and Burton NHS Foundation Trust.

 I am aware that my son/daughter may not be supervised during lunch and break times and
appreciate the placement is an open access public area and as such rely on my son/daughter
remaining on site during placement hours.

Signature: Date: _______________________________

School Careers Advisor/ Tutor:

I have read the work experience information and give permission for the candidate to attend the
course and observe during their visit to University Hospitals of Derby and Burton NHS Foundation
Trust. I also confirm that he/she is currently studying at ____________________________________

Signature: Date: _______________________________

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 Application for Work Experience or Observation Placement

Equal Opportunities Monitoring

As Public Sector Employers, NHS Organisations are required to collect the information regarding
protected characteristics as per Equality Act (2010). This information is collected to fulfil that
obligation and is used for monitoring purposes only.

I would describe my ethnic origin as follows:

Asian or Asian British Mixed Other Ethnic Group

☐ Bangladeshi ☐ White & Asian ☐ Chinese
☐ Indian ☐ White & Black African ☐ Any other ethnic group
☐ Pakistani ☐ White & Black Caribbean
☐ Any other Asian background ☐ Any other mixed background
Black or Black British White
☐ African ☐ British ☐ I do not wish to disclose my ethnic
☐ Caribbean ☐ Irish origin
☐ Any other Black background ☐ Any other White background

Please indicate your gender:

………………………………………………………………………… ☐ I do not wish to disclose my gender

Please indicate your age:

☐ 14-15 ☐ 16-18 ☐ 19-24 ☐ 25+

Please indicate your religion or belief:

☐ Atheism ☐ Islam ☐ Other

☐ Buddhism ☐ Jainism
☐ Christianity ☐ Judaism ☐ I do not wish to disclose my religion
☐ Hinduism ☐ Sikhism

Please indicate your marital status:

☐ Single ☐ Civil partnership ☐ Separated

☐ Married ☐ Co - habiting ☐ Divorced
☐ Widowed

Please indicate if you have any dependants:

☐ Yes ☐ No

Under the terms of the Act a disability is defined as a 'physical or mental impairment which has a substantial and long term
effect on a person's ability to carry out normal day to day activities'. We welcome applications from disabled people.

☐ Yes
Do you consider yourself to have additional needs/ a disability?
☐ No
☐ Yes
If yes, do you need special arrangements/support to enable you
to attend for a work experience placement? ☐ No

If so, please give details:

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 Application for Work Experience or Observation Placement

Please indicate the following: Participating with the following aim or purpose

☐ Gaining entry level employment

☐ Gaining access to higher education or professional training including medical school

☐ Part of organised work experience through school or college

☐ For own sake

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