Work Experience Application Form (Page 4 of 6) in pdf

Work Experience Application Form Page 4

4. Work Experience Application Form: Sensitive Patients Procedure

Pg 4 of 6

Dudley and Walsall Mental Health NHS Partnership Trust is committed to maintaining an open, honest

and well intentioned atmosphere so as to best fulfil the objectives of the Trust and NHS. The Trust

therefore requires you complete this declaration to ensure there are no issues that the Trust needs to be

aware of, which may potentially compromise either the position of the Trust or you.

Notification of any changes that occur prior to your placement starting should be reported immediately to

HR on 01384 324 526 / hrservices@dwmh.nhs.uk so that any potential compromise can be highlighted and

appropriate action taken to resolve the situation.

Are you aware of any of your relatives, or other people known to you,

Yes

accessing services within Dudley & Walsall Mental Health Partnership NHS

Trust?

If you have answered NO please proceed to the next page.

If you have answered YES, then for each person concerned please state below

Their name(s)

Their relationship to you or in

what capacity you know them.

Which services they normally

access

Signature

Print Name

Dated DD/MM/YY

Work Experience Application Form Page 4