Supervisors Report Form

Application for a Work Experience Placement

Please complete this application form in black ink and return to the Workforce Department, 3rd Floor Lichfield House, 27 – 31 Lichfield Street, Walsall WS21 1TE. Information will be treated in the strictest confidence.

Personal Details

Title: / Forename: / Surname:
Address for Correspondence:
Postcode:
Telephone Number: / DOB: / Age:
Email Address:
Next of Kin: / Daytime telephone Number:

School / College Details

School/College: / Address:
Careers Advisor: / Telephone Number:
Email Address of Career Advisor:

Work Experience Placement Details

Dates required for Work Experience:
Area/Department required/interested in:
Role required/interested in:
Explanation of why you are interested in the Area/Department and the Role you have stated above:

Previous Work Experience or Employment Details

Please give details of any previous paid or voluntary work carried out:

Employers details / Dates from/to / Role description

Qualification Details

Please give details of qualifications you have gained or are working towards:

Qualification: / Date(s): taken / Grade:

Student, Parent and Teacher Agreement

Work Experience Placement Requirements

The NHS Walsall Community Health 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 NHS Walsall Community Health will also expect you to sign in and out of NHS Buildings and 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 NHS Walsall Community Health fully supports equal opportunities in employment and opposes all forms of unlawful or unfair discrimination on the grounds of ethnicity, gender, disability, age, religion/belief or sexual orientation.

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

I have read and understood the above requirements.

Signed (student): / Date:

Please obtain the following signatures: (if you are under 18yrs. old)

Parent/Guardian

I have read and understood the work experience placement requirements (points 1 - 4 above). I will ensure the son/daughter carries out these obligations and confirm that he/she is not suffering from any complaint, which might create a hazard to him/her or to those working with him/her. I give permission for my son/daughter to attend work experience within NHS Walsall Community Health.

Signed (Parent/Guardian) / Date:

School Careers Advisor

I have read and understood the work experience placement requirements (points 1 – 4 above) and give permission for …………………………………………………….. to attend a work experience placement with NHS Walsall Community Health. I also confirm that he/she is currently studying at:

Signed (Careers Advisor) / Date:

Equalities Monitoring Form

The information provided on this form is confidential and anonymous and will only be used to monitor the makeup of applicants for a Work Experience or observation placement. The information is requested so that Walsall tPCT can monitor that it is complying with Equalities legislation as well as its own Equality Schemes.

GENDER: Please tick one of the boxes below
Female /  / Male / 
ETHNICITY: To which of these ethnic groups do you consider you belong? Please tick one of the boxes below. This information is required by the tPCT in order to comply with the Race Relations (Amendment) Act 2000 to ensure that no particular individual or group of people are discriminated against in the provision of services or employment opportunities
White / Mixed
British /  / White and Black Caribbean / 
Irish /  / White and Black African / 
Any other White background /  / White and Asian / 
Any other mixed background / 
Asian or Asian British
Indian /  / Black or Black British
Pakistani /  / Caribbean / 
Bangladeshi /  / African / 
Any other Asian background /  / Any other Black background / 
Any other Ethnic Group
Chinese /  / I do not wish to disclose this / 
Traveller / 
Gypsy / 
Any other ethnic group / 
DISABILITY: We have to ask if you are disabled as defined by the Disability Discrimination Act (1995). As a disabled person, under this definition, you have ‘… a physical or mental impairment which has a substantial and long-term adverse effect on his/her ability to carry out normal day-to-day activities.’
Do you consider yourself to be disabled under this definition?
Yes /  / No / 
AGE: Please write your date of birth below

Pre-placement Health Questionnaire

First Name::
Last Name
Date of Birth / Age:
Home Address:
Post Code:
Email Address:
Telephone Number:
1. / Do you have any illness at the present time?
If Yes, please give details: / Yes / No
2. / Do you consider yourself to have a disability/impairment/long term condition?
If yes, please give details advising of any adjustments you require to your working environment. / Yes / No
3. / Have you had any other serious illnesses or operations in the past?
If Yes, please give details: / Yes / No
4. / Are you taking or being prescribed any medicines, inhalers, injections or eye/ear drops at the present time?
If Yes, please give details: / Yes / No
5. / Is your ability to perform physical work limited in any way? / Yes / No
6. / Have you had or been in contact with any infectious disease in the past four weeks? / Yes / No
7 / Do you suffer from any allergies? / Yes / No

8.Which of the following infectious diseases have you been immunised against?

BCG (Tuberculosis) Pertussis (Whooping Cough)

Diphtheria Polio

Measles Rubella

Meningitis C Tetanus

Mumps

Note: In the event of any medical concerns raised from the answers you have provided above you may be referred to the Occupational Health Department for a medical opinion.

Signature: / Date:
Parent/Guardian’s signature if under 18:

If any of the above circumstances change from the time of completing the form to the time of placement you must inform the Workforce Department immediately.