Work Experience Participant

Application Form
Work Experience

Please note this information will be treated in the strictest confidence, however it may be shared with other
members of staff who may be involved in your work experience you application is successful. Please note,
completion of this form does not guarantee a work experience.

Please, if your placement request is T-Level related or looking for a structured long-term placement,
we will not be able to process your request because it does not fall within the remit of the Trust Work
Experience programme.

You must complete all sections

Dates of Work Department Click here to enter

Experience:
Click here to enter text. Requested: text.
Supervisor name (if Click here to enter
Click here to enter text. Career interested in:
known: text.

Personal Details

Click here to enter

Title: Click here to enter text. Forename:
text.
Click here to enter
Surname: Post code:
text.
Click here to enter
Telephone: Click here to enter text. Mobile:
text.
Click here to enter
Email Address: Click here to enter text. Age:
text.

Emergency Contact Details

Click here to enter

Name: Click here to enter text. Relationship to you: text.

Contact Number: Click here to enter text.

Click here to enter

Teacher
Name of School/College Click here to enter text. /Careers Advisor text.

Contact Number Click here to enter text.

Please ensure that you pay careful attention to this section, as how well you answer this section may
determine if your application is successful.

What are your expectations of Work Experience at Birmingham Women’s and Children’s
Hospital?
(Max. 150 words)
Click here to enter text.

OFFICE USE ONLY

Version: 2 Intranet x
Created on: 07/06/2018 Stored in: V:Drive x
Review date: 12/6/2019 Paper copies x
 How will work experience aid your future career plans?
(Max. 150 words)

Click here to enter text.

Supporting Information (Max. 250 words)

Supporting information can be anything that is not already covered elsewhere on the form and may
include hobbies and interests you enjoy
Click here to enter text.

_______________________________________________________________________

Rehabilitation of Offenders Act 1974

Work experience participants are exempt from the provisions of Section 4(2) of the Rehabilitation of Offenders
Act 1974. Therefore you are not entitled to withhold information about convictions for which other purposes
are termed ‘expired’.

Failure to disclose such information could result in the termination of the placement. All information provided is
confidential and will only be taken into account if necessary.

Have you ever been prosecuted/convicted/cautioned/ bound over?

Yes ☐ No ☐

If you have answered yes to the above, please give details.

____________________________________________________________________

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 Health Assessment Clearance

We need the below information to ensure our patients, staff and you are safe. This information means we can
plan your placement properly if you are selected.

Do you:
Have any illness at the moment?
Have you had any other serious illness or operation in the past 12 months?
Are you taking any prescribed any medication?
Is your ability to perform physical work limited in any way?
Have you had or been in contact with anyone with an infectious disease in the last month?
Have a learning disability that may affect your ability to understand or act on an instruction?
If one or more of the above applied to you please add more information here:

Which of the following infectious diseases have you been immunised

against?
BCG ✘ Mumps ✘ Tetanus ✘

(Tuberculosis)
Diphtheria Polio ✘
Hepatitis A ✘

Measles Pertussis (Whooping ✘

Hepatitis B ✘

cough)
Meningitis C ✘ Rubella ✘

COVID 1 COVID 2 COVID

Booster

Please note you may be asked to supply us with adequate vaccination history which you can obtain from your
GP. Information about the Vaccination Schedule is available on the NHS Choices website:
www.nhs.uk/Conditions/vaccinations/Pages/vaccination-schedule-age-checklist.aspx.

Please give details of any additional information, and any support you feel you would need whilst
on placement:
Click here to enter text.

Terms and conditions

Confidentiality: Any matters of a confidential nature, in particular information relating to the diagnosis and
treatment of patients, individual staff and/or patients records, and details of contract prices and terms must
under no circumstances be divulged or passed on to any other unauthorised person or persons. The
placement may be terminated if confidentiality is breached.

Even if you know a patient personally, you should not confirm their presence in the hospital to anyone else.

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You are not permitted to take any photos or videos and to put anything on social media even if no
names are used.

The Data Protection Act 1998 strictly regulates the storage and usage of information held on both manual
and computerised systems containing information about living persons. All participants involved in the use of
such systems are required to work in accordance with the law.

Local Induction: On the first morning of your placement, you will be given a Local Induction by your
placement supervisor. This will include general information about your placement, health and safety e.g. fire
safety, infection control, confidentiality, risk assessment and any other relevant information.

Dress Code: Clothes should be changed daily to minimise the risk of cross-infection. Shoes should cover
the whole foot and be low heeled. No jeans or trainers unless agreed with supervisor . Special requirements
as a result of cultural or religious obligations should comply with health and safety and infection control
precautions. Jewellery should not be worn, except for one pair of small studs, and a plain band/wedding ring.

Security: In the interest of security, you will be required to wear a name badge at all times. You must not
enter a ward or department area unsupervised. You are not permitted to make visits to other departments
unless accompanied by your supervisor.
Health and Safety at Work Act: In accordance with the Health and Safety at Work Act 1974, you have a
duty to take reasonable care to avoid injury to yourself and to others by your work activities and are required
to comply with the Trust Policies in meeting these statutory requirements.

You must be prepared for the fact that you may be prevented from attending planned sessions at very short
notice, and you may also be asked to leave a session if it is considered unsafe or inappropriate for you to be
present. You must comply with this, and any requests asking you to not enter, or to leave an area at any time.

Infection Control: Infection control is vitally important in all areas of the Hospital and in order to minimise the
risk of infection you must follow the instructions of your supervisor at all times. You must ensure that your
standards of personal hygiene are high by washing your hands at the beginning and end of each session,
before eating, and if you use the toilet facilities.

Loss/Damage of personal property: The Trust does not accept responsibility for loss or damage of
personal property belonging to you. You should, therefore, take care of all your belongings and consider
obtaining adequate insurance cover in respect of personal items of value.

During the period of your placement you will not, at any time, except where the law requires, be regarded as
an employee of the Trust, and will not be eligible for remuneration in respect of your work placement with the
Trust.

Work Experience Agreement / Consent

 I agree that while on Work Experience in clinical areas I will not attempt to undertake any task involving
direct contact with patients, I will follow the instructions of my Work Experience Supervisor and remain in
the area to which I have been allocated.
 To the best of my knowledge, I am not presently suffering from any illness or condition which could be
transmitted to patients or others.
 I agree to report to my supervisor if any of the above information changes or if at any time during my
placement I feel unwell or develop any symptoms, for example, skin rashes, diarrhoea or sickness, which
may adversely affect anyone with whom I am in contact.
 I confirm that the information given on this application is true and complete to the best of my knowledge
and belief. I understand that any false information could put patients at risk and result in my application
being refused or my Work Experience being cancelled.
 I agree to notify the Work Experience Team/ Work Experience Supervisor if my details change.
 I acknowledge I have read and understood the document.
 I understand the reasons for the collection of my personal information.
 I understand the ways in which my personal information may be used and disclosed.
 I acknowledge I provide this personal information to Birmingham Women’s and Children’s NHS Foundation
Trust and agree to the use and disclosure of my personal information as indicated here.
 I agree to be contacted by the Work Experience team during or after my work experience placement about
career opportunities, workshops or events organised by the organisation or other stakeholders.

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  I agree to provide information about my current education or career pathway when contacted by the Work
Experience team in the future as part of the commitment of the organisation to track the progress of all
students following the successful completion of their placements.
 I am happy to participate, and complete surveys or evaluation forms conducted by the Work Experience
team or on behalf of the organisation during or after the completion of my work experience placement. I
understand that my participation is voluntary and that I can choose not to participate in part or all of the
survey or evaluation exercise without being penalised or disadvantaged in any way.

Data protection
As part of the work experience application and management process, we will collect certain personal data, which we will process and hold
in accordance with the General Data Protection Regulation (GDPR), in force from 25 May 2018. This data will include your full name, date
of birth, address, email address, mobile number, school, college or other education information and dates of your placement. It will also
include, where supplied, your disabilities (if any), and occupational health background. This information will be held by us for the purpose
of assessing your suitability as a work experience participant.
We will not process your data for any other reason and will not share it with any third parties, other than those which are contracted to
help us to carry out this work. If your application is unsuccessful, we will hold your data for 12 months, and then destroy it. If you are
successful, we will hold your data for the duration of your time with us, plus an additional period of time (between 12 – 24 months), before
destroying it. At the end of your placement, you may be contacted about completing an evaluation form or survey as stated in the Work
Experience agreement. This form is anonymous and is used to help us evaluate and develop our work experience service.
Please indicate that you give your consent to be added to our work experience database

I consent to being added to the work experience database ✘

Participant Signature Click here to enter text. Date Click here to enter text.

Please obtain the following signatures if under 18yrs:

Parent Signature: Click here to enter text. Date Click here to enter text.

* Typing in the name acts as the signature

EQUALITY & DIVERSITY MONITORING

GENDER

MALE

FEMALE

NON-BINARY

SELF IDENTIFY AS

Prefer not to say

Is your gender identity the same sex as you

were assigned at birth?

YES/NO

Prefer not to say

AGE

AREA YOU LIVE

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Birmingham Women’s and Children’s NHS Foundation Trust aims to provide equal opportunities and fair
treatment for all.
The information below is anonymous and will not be stored with any identifying information about you. All
details are held in accordance with the Data Protection Act 1998, In order to help us understand who we are
reaching and to better serve everyone in our community.

The information will be used to provide an overall profile analysis of applicants. If you would like the form in
an alternative format or would like help in completing the form, please contact a member of staff.

Ethnicity
Please state what you consider your ethnic origin to be. Ethnicity is distinct from nationality and the categories
below are based on the 2001 Census in alphabetical order (please tick one)

ASIAN BLACK CHINESE OR MIXED WHITE

OTHER
Indian ( ) Caribbean ( ) ETHNIC White & Black English ( )
Pakistani ( ) African ( ) GROUP Caribbean ( ) Irish ( )
Bangladeshi ( ) Any other Black Any other mixed Scottish ( )
Any other Asian background Chinese ( ) background ( ) Welsh ( )
background ( ) (please state) Any other Any other group
ethnic group (please state)
(please state)

RELIGION/BELIEF (Please state if applicable)

SEXUALITY

Gay Gay Man Bisexual Heterosexual/Straight Prefer not to say

Woman/Lesbian
Pregnancy & Maternity (please Prefer not to say
state if applicable)
Marital Status / Civil Partnership Prefer not to say
(please state if applicable)

DISABILITY
The Equality Act 2010 defines a disability as a ‘physical or mental impairment which has a long-term and
substantial adverse effect on their ability to carry out normal day-to-day activities’. In this definition
“substantial means more than minor or trivial” and “long-term means that the impairment has lasted or is likely
to last for at least 12 months”. This includes conditions such as MS, HIV and cancer from the point of
diagnosis.

Do you consider yourself to have a disability according to YES NO Prefer not to

the above definition? (Please tick if applicable) say

Please note, completion of this form does not guarantee work experience.

Please send this completed form electronically to your Work Experience Supervisor

and a copy to the Work Experience inbox bwc.workexperience@nhs.net