WORK EXPERIENCE APPLICATION FORM

This form is to be completed by the person undertaking the placement. It is your

responsibility to make sure that all sections in this form are completed in full.
Applications with missing information will not be processed. Please complete this
form and return to [email protected] or
[email protected]

SECTION 1 – ABOUT YOU

First name: Aryo
Surname: Mortazavi
Date of Birth:
Gender: Male Female I do not wish to disclose

Address: 30 Guildford Drive

Chandler’s Ford
Eastleigh
SO53 3PT

Postcode: SO53 3PT Borough: Hampshire

Telephone: 07506864357
Email: [email protected]
Name, phone number and relationship of Next of Kin or in case of emergency contact:
Nazta Sayah
07800609597
Mother

Please indicate the type of school you currently attend or attended:

Fee Paying
Non-fee paying
I do not wish to disclose
Are you, or were you eligible for Free School Meals?
Yes
No
I do not wish to disclose
Are you currently in Education?
Yes
No if no, please go to section 2
Name of School/College/ University:
Peter Symonds College

Is your School/College/ University based in…?

Southwark
Lambeth
Other, please state? Winchester
 SECTION 2 – THE PLACEMENT
In no more than 200 words, please tell us why you have applied for Work Experience at Guy’s and St
Thomas’s?
I am beyond thrilled by the world of dentistry and the experiences it has to offer. To me, dentistry is about
working diligently, performing in an articulate manner as a team but also leading independently in some areas
when necessary; I believe that at Guy’s hospital, I will further my understanding of the importance of
communication between patient and dentist and will gain an intrinsic appreciation for the hard-work and
dedication required in such an artistic, yet demanding profession. Dentistry requires extensive knowledge of
human anatomy, physiology and dental pathology, as well as technical skills; I know that Guy’s will help me
understand these fields more. Perhaps this hands-on experience can help me acquire practical skills that are
useful in future studies or job applications. I also believe this work experience can enhance my application for
dental school or other healthcare-related programmes.

Moreover, I have played piano for 12 years now and I am just finishing up my grade 8, so I have fine manual
dexterity. I am coming from Southampton, and because of school, I can only do the Monday and not the full
week.

What type of placement are you considering? Please tick all that apply:
Medicine Nursing Midwifery Dentistry
Other Clinical Medical Physics Pharmacy Admin and clerical
profession*
Human Resources Finance IT Other, please State:
*Clinical Roles includes, Physiotherapy, Radiography (diagnostic or therapeutic), Dietetics etc, please specify
below.
Department or field of interest, if applicable:
Dentistry

What would you like to learn and/or skills would you like to develop on your placement? Briefly
describe.
About the teeth, working in a clinical environment, dentist to patient relationships

Do you already have a work experience placement confirmed? If Yes, please complete the following:
Dates from: Dates to: Department: Name of supervisor:

If you do not have a work experience placement confirmed? What dates would you like your work
experience to take place?
From: 03/04/23 To: 03/04/23 Number of days/weeks: 1 day

SECTION 3 – EQUALITY AND DIVERSITY MONITORING

Please note that Guy’s & St Thomas’ NHS Foundation Trust is committed to ensuring that no job applicant,
employee or trainee receives less favourable treatment than others on the grounds of gender, sexual orientation,
marital status, responsibility for dependents, disability, race, national origin, age, religion, political or trade union
affiliations, HIV status or socio-economic background. To help Guy’s & St Thomas’ NHS Foundation Trust to
ensure that it’s policy is being carried out, would you please complete all parts of this form. The information will
be held confidentially and may be used solely for monitoring purposes.

Please can you indicate your ethnic background:

White British Black or Black Asian or Asian Mixed – White & Black
British Caribbean British – Indian Caribbean
White Irish
Black or Black Asian or Asian Mixed – White & Black
Any other white British African British – Pakistani African
background
Black or Black British Asian or Asian Mixed – White & Asian
Other British – Bangladeshi
Mixed Other
Asian or Asian
British Other
Chinese Any other ethnic group
Do you consider yourself to have a disability?

Yes No I do not wish to disclose

Are you or have you been in Local Authority care?

Yes No I do not wish to disclose

Are you, or were you eligible for Free School Meals?

Yes No I do not wish to disclose

Are you aged between 16-24yrs and not in Education, Employment or Training (NEET)?

Yes No I do not wish to disclose

If over 24yrs, are you currently unemployed and have been for at least 12 months?

Yes No I do not wish to disclose

SECTION 4 – APPLICANT DECLARATION

1. Confidentiality: During the course of your placement you may have access to information of a
confidential nature, in particular information relating to the diagnosis and treatment of patients, individual
staff and/or patients records, and details of contract prices and terms. You must under no circumstances
disclose any confidential information to any person or make use of the information either during or after
the placement. You should not access personal data that your supervisor has not instructed you to
access. Failure to follow these conditions, may lead to prosecution should we become involved in a case
of litigation instigated by the patient. If you disclose or misuse information we will terminate your
placement immediately. In certain circumstances you may also be liable to prosecution under the Data
Protection Act 1998.
2. Clinical Observation: Please note that until your 16th birthday there will be no clinical obersvation
allowed. If you are observing in clinical areas, you will be given an Immunity Screening Questionnaire to
complete and return to the Occupational Health Service. This service is confidential and they may contact
you to discuss your medical history further.
3. Health and Safety: Guy’s and St Thomas’ places considerable importance on the need for attention to
Health and Safety at work. You are reminded that in accordance with the Health and Safety at Work Act
1974, you have a duty to take reasonable care to avoid injury to yourself and to others by your work
activities, and are required to comply with the Trust policies in meeting these statutory requirements. A
copy of the health and safety policy is available for inspection.
 4. Fire Policy Procedure: All work experience students are asked to note and comply with the Hospital’s
Fire Procedure. A copy of the Trust Fire policy can be obtained from your supervisor. Fire Action Notices
are displayed in each department for your information, please make it your responsibility to locate and
read this notice. If you have any queries at all regarding fire procedures, please ask your mentor or the
person in charge of your allocated department for help.
5. No Smoking Policy: Please note that there is a No Smoking Policy covering the whole working
environment and that there are security arrangements applicable to most locations.
6. Criminal Record: Any convictions, cautions or bindovers should be declared. Please contact me to
discuss this if it affects you.
7. Raising a Matter of Concern: If you see or hear anything that concerns you, please notify your
supervisor in the first instance.
8. Attendance: It is very important that you arrive on time each day, and after lunch. Staff are very busy and
will not want to waste time waiting. Make sure you leave yourself plenty of time to find your way to where
you are working. If for any reason you are unable to attend your work experience you must call on giving
your reason. If you attend school or college you will also need to let them know. Lack of attendance may
result in your placement being withdrawn.
9. Hours and lunch: Your hours will be 9am to 5pm, with 30mins for lunch. There are a number of places
for you to buy sandwiches, hot meals and drinks. Alternatively, you may wish to bring your own lunch.
Please note, there will normally be no payment for meals or travelling expenses.
10. Dress Code: Dress should be suitable for the professional work environment and the nature of the work.
In the case of service user contact, clothing should not progress beyond the elbow. Dress should not
cause embarrassment to colleagues, service users or visitors. Skirts or shorts if worn must be knee length
and tops should cover the shoulder, with a suitable neckline. All clothing and shoes should meet health
and safety requirements. More informal clothes may be worn on Fridays, but consideration must be given
in case of ad-hoc meetings that may occur, in which case no denim or very casual wear is acceptable,
especially in meetings where outside organisations are present. Shoes should be smart, sensible,
suitable for the weather and job, and reduce the risk of a slip, trip or fall.
11. Loss/Damage of Personal Effects: No liability can be accepted for loss or damage to personal property
on our premises by burglary, fire, theft, or otherwise. You are advised accordingly to provide your own
insurance cover.
12. Reimbursements: During the period of your placement you will not, at any time, except where the law
requires, be regarded as an employee of the Trust, and will not be eligible for remuneration in respect of
your work placement with the Trust.

I have read, understood the above requirements and have completed the form in full.
Signature Aryo Mortazavi Date 02/03/23

SECTION 5 – PARENT/GUARDIAN/CARER INFORMATION

If you are under 18yrs this section MUST be completed by your parent/guardian or carer
Title: (Mr/Mrs/Ms/Other) Name: Nazta Sayah

Relationship to the Mother

applicant:
Have you or your partner completed higher education or gained a professional qualification in this
country? (E.g. University degree, teacher training)
Yes, my partner has No, neither of us I do not wish to
Yes, I have
have disclose
Is your son/daughter eligible for Free School Meals?
Yes No I do not wish to disclose

Parent/Guardian/Carer Declaration:
I have read the work experience/observation information and understood 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/her or to those working with him/her. I give permission for my son/daughter to attend the
placement and observe during his/her visit to the Guy’s and St Thomas’ NHS Foundation Trust.
Signature Nazta Sayah Date 02/03/23

SECTION 6 – TEACHER/CAREERS ADVISOR

If you are under 18yrs this section MUST be completed by your Teacher or your Careers Advisor

Name: Job title

Teacher/Careers Advisor Declaration:

I have read the work experience/observation information and give permission for this student to attend the
placement and observe during his/her visit to Guy’s and St Thomas’ NHS Foundation Trust. I also confirm that
he/she is currently studying at:

Name of school/college:
Signature Date

Before you submit this application please check that all the all sections of this form have
been completed in full. Applications with missing information will not be processed.

Thank you for completing, please return to [email protected] or

[email protected]