FORM A Occupational Health Declaration Form for School Work Shadowing Programme for Students. Your Name: Your Address: Your Date or Birth: Age:

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1 FORM A Occupational Health Declaration Form for School Work Shadowing Programme for Students Your Name: Your Address: Your Date or Birth: Age: Date: Please tick yes or no to the following questions and return by to the contact person at your agreed placement 1. Do you have any health problems which may prevent you from undertaking this placement or could be made worse by undertaking this placement? 2. Do you have a disability (this could include any long term health problem, for example mental health problems, HIV epilepsy)? 3. Are you receiving any medical treatment for any medical condition at the moment? 4. Have you spent more than 12 weeks outside the UK in the last 12 months? 5. Please state any other information that you feel may be relevant. If the answer to questions 1 4 is yes, your placement sponsor will you the full occupational health screening form to complete and return to the Occupational Health department for their clearance prior to you undertaking the placement. This can take up to 6 8 weeks and the placement cannot be undertaken until clearance is received. If you have suffered from an episode of diarrhoea and/or vomiting less than 48 hours before your work experience/shadowing is due to start, then you should not start your placement and must telephone the Occupational Health department for advice and information. You must then contact your placement sponsor to make them aware of the situation. The Trust reserves the right to terminate any placements with immediate effect if something not previously disclosed should come to light which could potentially put individuals within the Trust at risk. Please note - By ing this information to the Trust you confirm that the information given by you is true, accurate and complete in all respects.

2 FORM B CRIMINAL CONVICTIONS DECLARATION FORM As an NHS Trust, we have a duty to protect the patients and children within our care and it is essential that everybody who works for us is trustworthy and reliable. As part of the selection process, you are required to answer the questions below to help us assess your suitability for the placement. Any information you provide may be discussed during the application process. Declaring a conviction, police caution, formal warning, reprimand or information about your professional status does not mean that you will not be considered for the placement we will pay very careful consideration to the nature of the information you provide and consider carefully how it may affect the placement you have applied for. Please be assured that any information declared to us will be treated with the utmost confidentiality. Once you have completed this form, please with your application. If you do not understand any of the questions, please contact the recruitment office within the Human Resources Department. Your Name Placement Position Please tick relevant box Is this Work Shadowing (Clinical Staff) Is this Work Experience (Non-Clinical Staff) ALL CANDIDATES TO ANSWER ALL QUESTIONS ON THS FORM Have you ever been bound over or ever been convicted of a criminal offence in the United Kingdom, or in any other country? Have you been charged with a criminal offence that has not yet been disposed of? Have you ever received a police caution, formal warning or reprimand? Are you, to your knowledge, the subject of a police investigation, whether in the United Kingdom or any other country? Please note - By ing this information to the Trust you confirm that the information given by you is true, accurate and complete in all respects.

3 FORM C WORK SHADOWING AGREEMENT 1. The placement will be without remuneration from the Trust. Travelling expenses, course fees, subsistence etc will not be met by the Trust. 2. The Trust has an obligation under the Health and Safety at Work Act 1974 to provide safe and healthy working conditions and methods. You are required to co-operate with management in discharging its responsibilities under the Act and to take reasonable care for the health and safety of yourself and others. 3. During the course of the placement you may have access to see or hear information of a confidential nature. All information concerning patients and staff is strictly confidential. You must not disclose any confidential information to anyone outside the Trust or anyone within the Trust who is not authorised to have such confidential information. Any breach of confidentiality will result in discontinuation of the placement. 4. Either you or the Trust may terminate this work shadowing arrangement without notice. 5. In the event of any allegations of misconduct, this work shadowing placement may be terminated by the Trust without notice. 6. Nothing in these conditions creates, or deems to create, a contract of employment between you and the Trust and you will not be entitled to any payment on the cessation or discontinuance of your work shadowing placement. 7. If, for any reason, eg. sickness, you are unable to attend for the purpose of your placement, you or someone of your behalf should telephone your placement sponsor as soon as possible. 8. Whilst on work shadowing placement you will comply with Trust policies and procedures including the Work Shadowing Policy and Procedures for Clinical Placements, Bare Below the Elbows Protocol, and Infection Control generally. 9. The Trust does not accept responsibility for personal property lost or damaged on Trust property and recommends that you should insure these. Do not wear any jewellery at work. 10. The Trust agrees to indemnify you against any legal claims arising from the proper execution of your recognised duties on Trust or other authorised premises. The Trust holds Employer Liability Insurance NHS Litigation Authority membership number T You are responsible to your placement sponsor and must act in accordance with their instructions. 12. You are required to assist in the investigation of untoward incidents if applicable and if requested, supply a written statement and give evidence as a witness on behalf of the Trust. 13. You are requested to declare in writing to the Chief Executive any financial interests you may have in relation to any order or contract placed/entered into by The Trust. I.. (name) hereby accept this placement on the terms specified above. Signed Date Print Name.. Contact Number.. Signed (parent/guardian). Date... Print Name. Contact Number....

4 FORM D RISK ASSESSMENT CHECKLIST WORK SHADOWING PLACEMENTS FOR SCHOOL STUDENTS To be done by placement sponsor or local placement co-ordinator prior to commencement of placement, and with consideration of the age, maturity and any specific needs of the student being placed. Name of Student Dates of Placement Area assessed and date Tasks/activities that a student may undertake or observe Dress code rules on clothing and jewellery Are there any particular health risks specific to the placement environment/s? eg. Length of VDU use, lifting objects, observing exposure prone procedures, ionizing radiations? If yes, give details below and state how risk is managed: Your name and job title You must a copy of this form to the student and to the school work experience coordinator for forwarding to parent/guardian of student, and to the manager of the area the student will be placed in prior to the placement starting. Individual risk assessments may be required for some activities such as working with VDU equipment, basic manual handling or fire safety. These forms are available on the Trust intranet. The Risk Management Unit and Occupational Health Department can be contacted for further assistance if required.

5 FORM E LOCAL INDUCTION CHECKLIST FOR WORK SHADOWING STUDENTS This induction must be completed by the student and the placement sponsor or coordinator on the first day of the placement. Where items are not applicable please indicate. 1. Student Details Name: Placement Sponsor: Department: Start Date: 2. Introductions or N/A Introduce to relevant colleagues/teams Who to go to if there is a problem Date completed and sponsor signature 3. Facilities Tour of office/work area Restaurant/coffee facilities Staff facilities eg. toilets 4. Health and Safety Fire safety/evacuation Trust security/alarms First Aid Infection Control Local safe systems of work 5. Terms and Conditions/Policies and Procedures Hours of attendance at placement Breaks Sickness or other absence notification procedure Alcohol and smoking Confidentiality, and implications of breach of Data Protection Act 6. Working Arrangements Telephone System Photocopier/fax Machine Departmental Dress Code Other (please specify) Signature of Student:.. Date... Signature of Sponsor:.. Date... ORIGINAL TO BE KEPT IN PLACEMENT AREA