Forename(s) Surname Male Female 16 19 to 24 Age Gender 16 to 18 25+ I do not wish to disclose gender I would describe my ethnic origin as follows: WHITE British BLACK or BLACK BRITISH Caribbean – – WHITE Irish BLACK or BLACK BRITISH African – – WHITE Any other White background BLACK or BLACK BRITISH Any other Black background – – ASIAN or ASIAN BRITISH Indian MIXED White and Black Caribbean – – ASIAN or ASIAN BRITISH Pakistani White and Black African – – or ASIAN BRITISH Bangladeshi MIXED White and Asian – – ASIAN or ASIAN BRITISH Any other Asian background MIXED Any other Mixed background – – ETHNIC GROUP Chinese – I do not wish to disclose my ethnic origin OTHER ETHNIC GROUP Any other Ethnic group – Yes No Do you have a disability you would like to make us aware of? If yes, please specify: *For Office Use Only* Start date End Date Allocated sector placement Clinical Non-Clinical
Forename(s) Surname Age 16 16 to 18 19 to 24 25+ Gender Male Female I do not wish to disclose gender I would describe my ethnic origin as follows: WHITE – British WHITE – Irish WHITE – Any other White background BLACK or BLACK BRITISH – Caribbean BLACK or BLACK BRITISH – African BLACK or BLACK BRITISH – Any other Black background ASIAN or ASIAN BRITISH – Indian ASIAN or ASIAN BRITISH – Pakistani or ASIAN BRITISH – Bangladeshi ASIAN or ASIAN BRITISH – Any other Asian background MIXED – White and Black Caribbean – White and Black African MIXED – White and Asian MIXED – Any other Mixed background ETHNIC GROUP – Chinese OTHER ETHNIC GROUP – Any other Ethnic group I do not wish to disclose my ethnic origin Do you have a disability you would like to make us aware of? Yes No If yes, please specify: *For Office Use Only* Start date End Date Allocated sector placement Clinical Non-Clinical
South%20Tees%20NHS%20Work%20Experience%20Application%20Pack.docx