Open door application - online form - Staffordshire County Council

Part 3 - Work placement
Please indicate the type of work placement you would be interested in undertaking to develop your skills and experience.
Please note: Whilst we endeavour to place the candidate according to their interests, Staffordshire County Council cannot guarantee placement preferences.

Part 3 - Work placement
Which days in a week would you be able to work?
MondayTuesdayWednesdayThursdayFriday
Are there any specific hours you'll be available to work?
Have you been referred by an agency?
YesNo

Part 3 - Work placement
Please give details of any experience and skills you may have which could be relevant.
What do you hope to achieve from an open door placement?

Part 4 - Your learning
Do you have any medical conditions or disabilities?
YesNo
If yes, please specify
Are there any potential challenges or restrictions you could experience whilst carrying out your work placement?
Do you require and special adjustments to undertake a work placement?

Part 4 - Your learning
Do you have a driving licence?
YesNo
If yes, do you have access to a vehicle?
YesNo
How far are you willing to travel for your work placement within Staffordshire?
Please note: whilst we endeavour to find a placement close to the candidate's home, this may not always be possible depending on placement availability. Travel expenses cannot be covered by the open door programme.

Part 6 - References
If you do not have employment history then please provide details of two education referees.
Referee 1

First name

Last name
Occupation
Location of work
Email
Phone
Referee 2

First name

Last name
Occupation
Location of work
Email
Phone

Part 8 - Other experience
Please provide any skills or training you have had including particular experiences, knowledge, on the job training, voluntary experience or hobbies.

Equal opportunities
As part of your equal opportunities policy we request that you complete the following form. This information is for monitoring purposes only.
All information will be treated as confidential and will not be used when deciding on whether an applicant is successful or unsuccessful in obtaining a placement.
The information you provide will help us to ensure that our recruitment procedures are fair by allowing us to identify and eliminate potential areas of descrimination.
Please specify your ethnic origin
Other - please specify
Please indicate your religion / belief
Please indicate your sexual orientation
Please indicate your gender
MaleFemaleOther

Disabilities
The Disability Discrimination Act (2010) defines a disabled person as someone with a physical or mental impairment which has substantial long term adverse effect on their ability to carry out normal day to day activities.
Do you consider yourself to have such a disability?
YesNo
Please in
Do not wish to specifyLearning difficultiesLearning disabilityLong standing illness or health conditionMental health conditionMental illnessMobility impairmentHearing impairmentPhysical co-ordination difficultiesPhysical impairmentReduced physical capacitySensory impairmentSpeech impairmentVisual impairment (not corrected by glasses or contact lenses)Neurological conditionOther

Our use of cookies