Work Experience Application Form Page 6
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66. Work Experience Application Form:
Equality and Diversity Questionnaire
Pg 6 of 6
As an NHS organisation it’s important that we monitor the profile of all our placements, to ensure we are
providing equality of access and offer us insights into how to improve access. All information will be
treated in the strictest confidence but you do not have to answer any sections that you would rather not.
Ethnic origin (please circle)
White British
White Irish
Mixed White & Black
White any other background
Mixed White & Black African
Caribbean
Mixed White & Asian
Any other mixed background
Asian/Asian British Indian
Asian/Asian British
Asian/Asian British Pakistani
Any other Asian background
Bangladeshi
Black/Black British Caribbean
Black/Black British African
Any other black background
Middle Eastern/Arab
Chinese
Eastern European
background
Gypsy/Roma/Traveller
Any other ethnic group
Not Stated
Religion/religious belief/or none
Marital status
Gender (please circle)
Male
Female
Other
Any disability (please
state)
Sexuality (please state)
Age (please circle)
Under 18
18 to 29
30 to 39
40 to 49
50 to 59
60 to 69
70 and over
When completed scan and email to trainingbooking@dwmh.nhs.uk
INCLUDING YOUR FULL NAME IN THE SUBJECT LINE or post to:
Dudley & Walsall Mental Health Partnership NHS Trust, Learning & Development Dept.,
nd
Trafalgar House, 2
Floor, 47-49 King Street, Dudley, DY2 8PS.
Please allow up to 10 working days for a response by email or phone, if the form is not completed
fully it will delay & may also affect your application.
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