Aspiring Doctors’ Programme
WEDNESDAY 30th May 2018

South Staffordshire and Shropshire Healthcare NHS Foundation Trust are holding a one day Work Experience Programme for students aged 14+ years who are interested in pursuing a career in medicine and/or might be considering a career in psychiatry.

The event aims to inspire and inform students about psychiatry, how to pursue a career in psychiatry and gain a basic understanding of what it is like to work as a doctor in mental health. There will be the opportunity to speak to a variety of clinicians working within various different areas of mental health and visit a mental healthcare setting. You will take part in interactive activities which aim to not only highlight the exciting challenges involved in a career in psychiatry, but also give insight and information regarding mental illness. The programme will be hosted at our Learning Centre on St.George’s Hospital site in Stafford, on
Wednesday 30th May 2018. Lunches and refreshments will be provided.

As places are limited, so in order to help us select students and find out a little more about yourself we ask you to write a paragraph or two describing why you would like to attend this programme and what interests you about undertaking a career in medicine and in particular psychiatry. Please fill out the box on the other side of this sheet also, noting any dietary requirements at the bottom of the form, and submit the following completed forms.

  • Work Experience Application Form
  • Confidential Pre-Placement Health Questionnaire

The closing date for application forms is Friday 30thMarch 2018.

Why would you like a place on the Aspiring Doctors Programme? This is your opportunity to promote yourself and to identify why you have a specific interest in pursuing a career in medicine and more specifically in mental health. Please use the space to provide at least two paragraphs describing why you have an interest in attending our programme and why you specifically would be interested in psychiatry.

Name of Student: Date of Birth:

Dietary Requirements:

APPLICATION FOR ASPIRING DOCTORS PROGRAMME

Please complete this application form in black ink. Information will be treated in the strictest of confidence.

  1. Personal Details

Title: / / Surname: / / Forename: /
Address for Correspondence: /
/ Postcode:
Date of Birth: / / Email: /
Telephone No. / / Mobile: /
Contact in case of Emergency: / / Relationship: / Tel No.
School/College/University: /
Teacher Contact: / / Tel No. /
  1. Code of Conduct

General Conduct

  • Be polite, courteous and smile - it will help to put the staff, patients and relatives in a more relaxed mood – it is contagious!
  • Show that you care – make people feel that they matter by being attentive and showing interest.

Confidentiality

It is essential that patients are assured of complete confidentiality in all aspects of their care at all times. You should follow the simple rules given below:

  • You MUST NOT disclose to any unauthorised person the fact that a patient has been connected with the organisation. This includes people who might be known to you personally.
  • You MUST NOT disclose any information about a patients/clients condition or treatment or any other details learnt about the patient/client.
  • You MUST NOT discuss confidential information concerning patients/clients in public areas e.g. whilst waiting at the bus stop, back at school/college/university or at home with your family.

Punctuality and Attendance

  • Notify the organisation if you are going to be late or unable to attend.

Dress

Your dress and appearance are important for two main reasons; firstly, because we are providing a service, and, secondly for health and safety reasons.

  • Be neat, tidy and respectably dressed and pay attention to personal hygiene.

I have read and understood the above requirements.

Signed (Student): / Date:
Please state your age:

Student, Parent and Teacher agreement to the NHS Organisation Requirements

  1. Attention to Health & Safety at work is paramount at South Staffordshire and Shropshire Healthcare NHS Foundation Trust. 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.
  2. South Staffordshire and Shropshire Healthcare NHS Foundation 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 security arrangements applicable to most locations.
  3. South Staffordshire and Shropshire Healthcare NHS Foundation 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.
  4. There will be no payment for meals.

If successful, I agree to work with the departmental guidelines and follow instructions given.

I have read and understood the above requirements.

Signed (student): / Date:

If the Applicant is under 18, please obtain the following signatures:

Parent/Guardian

I have read the programme information and understand the requirements. I will ensure the student carries out these obligations and confirm that he/she is not suffering from any complaint, which might create a hazard to him/herself or to those working with him/her. I give permission for my son/daughter______to attend the event and observe during his/her visit to South Staffordshire and Shropshire Healthcare NHS Foundation Trust.

Signature: / Print Name:
Date:

Teacher/Work Experience Coordinator

I have read the programme information and give permission for ______to attend the eventat South Staffordshire and Shropshire Healthcare NHS Foundation Trust. I also confirm that he/she is studying at ______

Signature: / Print Name:
Date:
  1. Equality & Diversity Monitoring

South Staffordshire and Shropshire Healthcare NHS Foundation Trust recognise and actively promote the benefits of a diverse workforce and are committed to treating all employees and work experience applicants with dignity and respect regardless of age, disability, gender reassignment, marriage and civil partnership, pregnancy and maternity, race, religion or belief, sex and sexual orientation. We therefore welcome applications from all sections of the community.

Date of Birth /
Gender / Male/Female (please circle one)

Equality Act 2010

As Public Sector Employers, NHS organisations are required to collect details about an applicant's ethnicity. This information is collected to fulfill that obligation and is used for monitoring purposes only.

I would describe my ethnic origin as: (please tick one)

WHITE– British / 
WHITE– Irish / 
WHITE - Any other background / 
ASIAN or ASIAN BRITISH – Indian / 
ASIAN or ASIAN BRITISH – Pakistani / 
ASIAN or ASIAN BRITISH – Bangladeshi / 
ASIAN or ASIAN BRITISH – Any other Asian Background / 
MIXED – White & Afro Caribbean / 
MIXED – White & Black African / 
MIXED – White & Asian / 
MIXED – any other mixed background / 
BLACK or BLACK BRITISH – Caribbean / 
BLACK or BLACK BRITISH – African / 
BLACK or BLACK BRITISH – Any other black background / 
OTHER ETHNIC GROUP – Chinese / 
OTHER ETHNIC GROUP – Any other ethnic group / 
I do not wish to disclose my ethnic origin / 

Equality Act 2010

In order to comply with these regulations NHS organisations are monitoring sexual orientation and religion/belief in applications. Please answer the following questions:

Please indicate which term would best describe your sexual orientation:

Lesbian / 
Gay / 
Bisexual / 
Heterosexual / 
I do not wish to disclose my sexual orientation / 

Please indicate your religion or belief: (please tick one)

Atheism / 
Buddhism / 
Christianity / 
Hinduism / 
Islam / 
Jainism / 
Judaism / 
Sikhism / 
Other / 
I do not wish to disclose my religion / belief / 

The Equality Act 2010 protects disabled people - including those with long term health conditions, learning disabilities and so called "hidden" disabilities such as dyslexia. If you tell us that you have a disability we can make reasonable adjustments to ensure that any selection processes - including the interview - are fair and equitable.

Do you consider yourself to have a disability? (please tick one)

Yes / 
No / 
I do not wish to disclose whether or not I have a disability. / 

Please state the type of impairment which applies to you. People may experience more than one type of impairment, in which case you may indicate more than one. If none of the categories apply, please mark ‘Other’.

Physical Impairment / 
Sensory Impairment / 
Mental Health Condition / 
Learning Disability / Difficulty / 
Long Standing Illness / 
Other / 

Confidential Pre-placement Health Questionnaire

Please complete this application form in black ink. Information will be treated in the strictest confidence.

Student Name: / / Date of Birth:
Home Address / Street Name and No. /
Area: /
Town: /
County: /
Post Code: /
Home Phone: / / Mobile Phone No.: /
  1. Do you have any illness or disability at the present time?
/ Yes ☐ / No☐
If Yes, please give details:

  1. Have you had any other serious illnesses or operations in the past?
/ Yes ☐ / No☐
If Yes, please give details:

  1. Are you taking or being prescribed any medicines, inhalers
    injections or eye/ear drops at the present time?
/ Yes ☐ / No☐
If Yes, please give details:

  1. Is your ability to perform physical work limited in any way?
/ Yes ☐ / No☐
  1. Have you been in contact with any infectious disease in the past four weeks?
/ Yes ☐ / No☐
  1. Which of the following infectious diseases have you been immunised against?

☐ BCG (Turberculosis) / ☐ Pertussis (Whooping Cough / ☐Diptheria / ☐ Polio
☐ Measles / ☐ Rubella / ☐ Meningitis C / ☐ Tetanus
☐ Mumps
  1. Do you suffer from allergies? If so, state what you are allergic to.
/ Yes ☐ / No☐
Signed (student): / Date:
Parent/Guardian’s signature if under 18: