Work Placement Request

Thank you for considering Trinity Hospice and Brian House Children's Hospice for your placement.

Please note, we can only accept placement request for students over the age of 18 unless by special arrangement.
We prefer a minimum of one month's notice for all placement requests.

About You

Name*

First Last

Date of birth*

Email*

Daytime telephone*

What is your current course?*

Higher Education Provider or University*

Year of study*

Please confirm that you have the following in place:

Current DBS*

Yes

No

Occupational Health Clearence*

Yes

No

Valid ID*

For example, Student ID badge or driving licence

Yes

No

Link Contacts

Academic contact name*

For example, your personal tutor or academic assessor

First Last

Academic Contact Role*

Academic Contact Email*

Academic Contact daytime telephone*

Are you already on another placement, and therefore this is a request for a short 'spoke' placement?*

Yes

No

Current placement location*

Name of assessor*

First Last

Assessor Email*

Assessor daytime telephone*

Emergency Contact Name*

First Last

Emergency Contact relationship*

Emergency Contact telephone*

About your placement request

Please indicate which departments you would like experience of*

Please note, placements over one week may include weekend shifts and/or nights

Adult In-patient Unit

Community Palliative Care Team

Hospital Palliative Care Team

Brian House Children's Hospice

Hospice at Home (community team - nights)

Lymphoedema Outpatient Clinic

Please indicate the dates and length of placement you are requesting*

If you have several options, please list all dates available

What is your preferred shift pattern?

For example, how many hours, days and weeks?

Learning Needs

What are your specific learning needs for this placement?*

If you have any experience of palliative care, please explain here:

Please provide any additional information to enable us to support you on this placement:

Consent for information storage

Do you consent to the information you have shared being electronically stored for information and audit purposes only?
Your contact information will not be shared outside of the Education Team unless you are offered a placement. Appropriate information on this form may be shared with the department you have requested placement in while your application is processed however.

Consent*

YES I consent

NO I do not consent

Thank you for considering Trinity Hospice and Brian House Children's Hospice for your placement.

About You

Link Contacts

About your placement request

Learning Needs

Consent for information storage

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