Dementia in Context for Health and Social Care Application Guidance

Transcription

1 Dementia in Context for Health and Social Care Application Guidance We are pleased that you are interested in applying for the Dementia in Context for Health and Social Care stand-alone module at the Faculty of Health and Life Sciences, Oxford Brookes niversity. To help you through the application process this pack includes a checklist with everything that you will need to return to us in order to be considered for a place on the course. Application form You will first need to choose which level you want to study undergraduate or postgraduate and select the appropriate form: Modular rogramme (M2) for undergraduate; ostgraduate Associate Study Application for postgraduate. You will need to provide various details about yourself, your residency, and your professional and educational histories. You will also need to complete a statement explaining why you wish to undertake the module (on the second page of the application); this will be an important factor in how your application is assessed. The Module No. for Level 5 (undergraduate) is The Module No. for Level 7 (postgraduate) is Manager s Supporting Statement You will need to ensure that the Manager s Supporting Statement is completed by your Manager. LBR Core Funding Statement This form needs to be completed if you are being sponsored by an NHS Trust under the CORE Learning Beyond Registration (LBR) contract. This includes all NHS Trusts in Oxfordshire, Berkshire and Buckinghamshire and the South Central Ambulance Service. lease fill in the LBR Core Funding Form and tick one of the options regarding funding. This form then needs to be signed by your Trust Education Lead. If you are being funded through another source you will need to provide confirmation in writing from the organisation concerned, including invoice details. If you will be self-funding you will need to confirm this in writing. lease be aware that if you do not provide funding information with your application, this will delay the processing of your application and may result in you not being offered a place on the course. BEFORE YO SBMIT YOR ALICATION: Ensure the following have been signed by the persons detailed below: Application form LBR Funding Statement (Trust Education Lead) or other confirmation of funding Manager s Supporting Statement (Line Manager) If your documents are not completed and/or signed correctly, this will delay the processing of your application and may result in you not being offered a place on the course. Completed applications must be submitted to Huw Hallam (hhallam@brookes.ac.uk) by 8 December, Kind regards, Huw Hallam rogramme Administrator Faculty of Health and Life Sciences Oxford Brookes niversity

2 Modular ro g r a m m e Application for a place as an Associate Student on the Modular rogramme roposed start date art-time or full-time M2 Application Ref No: ersonal details Title Mr/Ms/Mrs/Miss Surname First name Date of birth Country of birth Home address ostcode Daytime telephone number address Disability/Special Needs Fee status Country of domicile or area of permanent residence Applicants not born in the European nion please state: Date of first entry to the E Date of most recent entry to the E Date from which you have been granted permanent residence in the E Nationality Reference Name and address of Referee Day Month Year lease enter the appropriate code in this box if you have a physical or sensory disability which might in some way affect your studies or may require special facilities or treatment. (See guidance notes.) lease clarify the type of disability or special needs Daytime telephone number: Student/Employment status If student, state course and college Criminal convictions If you have a relevant criminal conviction enter X in the box. (See notes for a definition of relevant criminal conviction.) If staff at Brookes, state Dept and position If employed, state where and nature of work Education or other relevant experience from age 16 Give names and towns of establishments attended in chronological order Month From Year Month To Year Full-time or art-time Examinations taken Examining body Exam date Month Year Subject Level Result M2-1

3 Modular rogramme Module selection lease indicate here the area of your interest, or the module(s) you wish to study, specifying both the name(s) and number(s) and the semester in which the module runs. art-time associates cannot apply for more than five modules over the academic year or 3 modules in any one semester as this would be classed as full-time. lease indicate here your reasons for applying to study as an Associate Student IMORTANT Continuing as an Associate from one year to the next If you are accepted as an Associate Student and you wish to register for further modules each semester or from one year to the next, you will not have to re-apply on an M2 application form. Further modules should be registered on an M100 form, obtainable from the Student Administration Office or from the rack outside the office. DECLARATION I confirm that the information given on this form is complete and accurate and no information requested or other material information has been omitted. I give my consent to the processing of my data by Oxford Brookes niversity. I have read the Conditions of Acceptance laid out in the rospectus and undertake to be bound by those conditions. Applicant s Signature... Date... FOR CO-ORDINATOR S SE Co-ordinator s decision nconditional Conditional Reject Comments (conditions) M2-2

4 ostgraduate Associate Study Application Application for a place as ostgraduate Associate Student roposed start date ersonal details Title Mr/Ms/Mrs/Miss Surname First name Date of birth Country of birth Home address ostcode Daytime telephone number address Disability/Special Needs art-time or full-time Application Ref No: Fee status Country of domicile or area of permanent residence Applicants not born in the European nion please state: Date of first entry to the E Date of most recent entry to the E Date from which you have been granted permanent residence in the E Nationality Reference Name and address of Referee Day Month Year lease enter the appropriate code in this box if you have a physical or sensory disability which might in some way affect your studies or may require special facilities or treatment. (See guidance notes.) lease clarify the type of disability or special needs Daytime telephone number: Student/Employment status If student, state course and college Criminal convictions If you have a relevant criminal conviction enter X in the box. (See notes for a definition of relevant criminal conviction.) If staff at Brookes, state department and position If employed, state where and nature of work Education or other relevant experience from age 16 Give names and towns of establishments attended in chronological order Month From Year Month To Year Full-time or art-time Examinations taken Examining body Exam date Month Year Subject Level Result 1

5 ostgraduate Associate rogramme nit selection lease indicate here the area of your interest, or the unit(s) you wish to study, specifying both the name(s) and number(s) and the semester in which the unit runs. lease state the Oxford Brookes niversity school at which you are applying to study. lease indicate here your reasons for applying to study as a ostgraduate Associate Student DECLARATION I confirm that the information given on this form is complete and accurate and no information requested or other material information has been omitted. I give my consent to the processing of my data by Oxford Brookes niversity. I have read the Conditions of Acceptance laid out in the rospectus and undertake to be bound by those conditions. Applicant s Signature... Date... FOR ADMINISTRATION SE Co-ordinator s decision nconditional Conditional Reject Comments (conditions) 2

6 Manager s Statement of Support The purpose of this form is to indicate to the niversity that the applicant has applied with the knowledge of their manager, and that the student will be provided with support and the learning outcomes will be achieved. Arrangements regarding study leave and support are entirely between the applicant and their manager. Student name : Short Course applied for: Brief student s statement for manager s information lease state why you wish to take this course and how it might impact on your professional practice. Manager s agreement to support application Agree, please tick. o Yes Manager signature: Date: Manager s name: Clinical Area:

7 Faculty of Health & Life Sciences LBR CORE FNDING STATEMENT, TO BE RETRNED WITH ALICATION FORM (lease complete ALL sections) Name: ractice area (e.g. cardiology/g surgery/community): Your name must appear here identically to how it does on your health care registration, including middle names if you have used them. Hospital/Institution (eg John Radcliffe Hospital): rofessional body registration number: Certificates of attainment cannot be given unless we have your registration number from your professional governing body. e.g. NMC IN, HCC registration lease list the module(s) name & number OR short course title and code: NHS Financial Year: Tick relevant box below for level of study: Associate - number of modules to be taken or full short course Dip HE BA BSc BA Hons BSc Hons G Cert G Dip MSc Course/module commencement date: Intended completion date: To be completed by your Trust Education lead: Trust Education Lead s Signature Date:.. Trust Education Lead s Name (please print) I work within Health Education England - Thames Valley (LETB) in one of the following Trusts (please tick) Trust Tick Trust Tick Royal Berkshire NHS Foundation Trust Berkshire Healthcare NHS Foundation Trust (Mental Health & inc. E & W Berks CT) Buckinghamshire Healthcare NHS Trust Milton Keynes General Hospital NHS Foundation Trust Milton Keynes Community Healthcare Oxford niversity NHS Trust Oxford Health NHS Foundation Trust South Central Ambulance Service NHS Foundation Trust Southern Health NHS Foundation Trust (reviously - Ridgeway artnership) (Learning Disability) Heatherwood and Wexham ark NHS Foundation Trust Office se Only: niversity Course Code. Speciality Code.. Continuing Student pdated 5/6/14 (AF)

8 LBR CORE Trust Sign Off NHS Trust Requiring Sign Off Berkshire Healthcare NHS Foundation Trust Trust Education staff who can sign off applications Mette Laszkiewicz, Julie Bennetts, Glenis Henry, Herjee Chana Buckinghamshire Healthcare NHS Trust Jan Marote, Monica Mendonca Heatherwood and Wexham ark Hospitals NHS Foundation Trust Milton Keynes Community Healthcare Milton Keynes Hospital NHS Foundation Trust Oxford niversity Hospital NHS Trust Oxford Health Jenny Simmons Alison Drage Sue Coombes, Wendy Bowes Sarah Stephenson, Laura Klee David Slingo, Sue Byrne, Julie Whelan Julie Anderson, Oxford Health Non-Medical rescribing only Sue Haines Southern Health NHS Foundation Trust Royal Berkshire NHS Foundation Trust South Central Ambulance Service NHS Trust Katharine Kerr, Louise Hartland Joan otterton, Jo Sandy Ian Teague, Christina Fowler, Heather Knight pdated 5/6/14 (AF)