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Work experience application form

Please read all of this information before starting the application form.

Dear Applicant

Re: Work Experience Application

Please note: This is not a Clinical/Observational Attachment Form

Thank you for expressing an interest in Work Experience at the University Hospitals of North Midlands NHS Trust. Please complete the on line application form.

Due to the nature of the work carried out at the University Hospitals of North Midlands NHS Trust, there are some necessary age restrictions in place. Please refer to the Department Age Restrictions for more information.

In order to process your application and organise an appropriate placement please complete your application form online at least 8 weeks prior to the dates you require. Please note you will be notified of your placement at least 2 weeks prior to the start of your placement.  

Please ensure that you complete all sections and include any information that may support your application, including details of anyone you have spoken to within the hospital regarding your placement. We will confirm receipt of your application via email. If you are under 18 years of age we will also send a receipt to your parents or carers email stated on the application.

Due to the high volume of applications we receive, we cannot guarantee every applicant a placement and we reserve the right to limit the number of placements offered. We would therefore strongly advise that you also consider alternative options for work experience if you are required to complete a mandatory placement.

If you require a paper copy or alternative format please contact 01782 672277 or email work experience work.experience@uhnm.nhs.uk.

Kind Regards

The Work Experience Team



The Work Experience you will be applying for has been identified as a regulated or controlled activity within the terms of the Safeguarding Vulnerable Groups Act (2006), and is eligible for a Declaration A check under the provisions of the Police Act 1997 (Criminal Records) Regulations (as amended).

Before you can be considered for a placement in regulated or controlled activity with University Hospitals of North Midlands NHS Trust we need to be satisfied about your character and suitability. Please read the following notes carefully before completing this declaration form. All enquiries will be treated in strict confidence.

We aim not to discriminate unfairly against applicants on the basis of criminal conviction or other information declared. Prior to making a final decision concerning your application, we shall discuss with you any information declared by you that we believe may have a bearing on your suitability for the position. If we do not raise this information with you, this is because we do not believe that it should be taken into account. In that event you may wish to discuss the matter with the Work Experience Coordinator.

The information that you provide in the work experience form will be processed in accordance with the Data Protection Act 1998. It will be used for the purpose of determining your application for this placement. It will also be used for purposes of enquiries in relation to the prevention and detection of fraud.

The Data Protection Act 1998 requires us to advise you that we will be processing your personal data. Processing includes: holding, obtaining, recording, using, sharing and deleting information. The Data Protection Act 1998 defines ‘sensitive personal data’ as racial or ethnic origin, political opinions, religious or other beliefs, trade union membership, physical or mental health, sexual life, criminal offences, criminal convictions, criminal proceedings, disposal or sentence; and (from 12 October 2010) will include any barring decisions made against the Children’s or Vulnerable Adults Lists by the Independent Safeguarding Authority under the terms of the Safeguarding Vulnerable Adults Act (2006).

The information that you provide in this Declaration Form will be processed in accordance with the Data Protection Act 1998. It will be used for the purpose of determining your application for this position. It will also be used for purposes of enquiries in relation to the prevention and detection of fraud.

Once a decision has been made concerning your placement, UHNM will not retain this declaration form any longer than necessary. This declaration will be kept securely and in confidence. Access to this information will be restricted to designated persons within the trust who are authorised to view it as a necessary part of their work.

I consent to the information provided in this declaration form being used by UHNM for the purpose of assessing my application, and for enquiries in relation to the prevention and detection of fraud. I confirm that the information that I have provided in this declaration form is correct and complete. I understand and accept that if I knowingly withhold information, or provide false or misleading information, this may result in my application being rejected, or if I am placed, in my dismissal, and I may be liable to prosecution.

By submitting the work experience form I confirm that the information contained on this application is correct

If any of the above circumstances change from the time of completing the form to the time of placement you must inform us straight away. If you wish to withdraw your consent at any time after completing this Declaration Form, please contact the Work Experience Team on 01782 672277.

By signing the Work Experience Agreement below – you are agreeing to the content, confidentiality and declaration in this form to which you are applying for a placement at UHNM.

  1. Placement Duration

The University Hospitals of North Midlands NHS Trust (“The Trust”) offers you a work experience placement for the period of no more than two weeks.  This is not a contract of employment.

  1. Placement Details

The specific details of the duties of your placement will be as agreed with the department. You will be expected to observe any rules and regulations, as directed by the department. The Trust reserves the right to terminate a placement immediately if your behaviour is deemed to be inappropriate and/or likely to bring the organisation into disrepute.

  1. Induction

As a condition of this agreement, you are required to complete a short work experience induction prior to commencement of your placement. Failure to complete the induction will result in the offer of a placement being withdrawn.

  1. Identity Badges

You are required to wear your identity badge at all times whilst on work experience. The badge will be issued on the first day of your placement at the Healthcare Careers and Skills Academy and must be returned there on the last day of your placement.

  1. Dress Code

You are required to wear smart casual clothing suitable for the workplace, i.e. no jeans or trainers (unless appropriate to the placement area.) Protective clothing must be worn where appropriate.

  1. Disciplinary & Grievance

Whilst on Work Experience the Trust is not your employer. Therefore you have no entitlement to grievance or disciplinary procedures.

  1. Concerns/ Complaints

Any concerns or complaints in regard to your work experience placement must be referred to either your placement supervisor or the work experience co-ordinator in the first instance, who will investigate and respond as appropriate.

  1. Confidentiality

It is a condition of your work experience placement that you will not disclose any confidential information other than to those who are authorised to receive it. In addition, if whilst on placement you have access to personal data, you have obligations under the Data Protection Act to maintain confidentiality of information. Contravention of this condition will result in your placement being terminated immediately.

  1. Health & Safety

The trust recognises its responsibilities under the Health & Safety at Work Act 1974 and the Management of Health & Safety at Work Regulations 1999 to ensure that the health, safety and welfare of all its workers is safeguarded, so far as is reasonably practical. You have a responsibility to observe safe working practices and to abide by the Trust’s safety policies and procedures.

  1. Personal Effects

Personal effects are not covered by any insurance taken out by the Trust. The Trust accepts no liability for loss or damage arising from fire, theft, etc. of any personal property on Trust premises or grounds.

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