Advanced / Non-Medical Prescribing Supplementary Information Form To be completed in addition to your online application form Please return by email to admissionscpd@anglia.ac.uk or by fax to 01245 684718 PART 1 To be completed by ALL applicants Name: Job Title: Time in current role: Note: this is the role in which you will prescribe Is your role primarily ambulance-based? Describe your current role and specialist area of practice: Nurse, midwife, health visitor or school nurse: NMC registration no: Paramedic, chiropodist, podiatrist, radiographer, physiotherapist: HCPC registration no: Pharmacist: GPhC registration no: No. of FULL years of postregistration experience: No. of FULL years of postregistration experience: No. of FULL years of patientoriented experience: Have you ever applied for and commenced a programme of prescribing preparation before? YES - please tell us the reason for non-completion: Are you being funded by your NHS TRUST? If YES, please enter details here: NHS Trust name: Education Lead name: If you are NOT being funded by your NHS TRUST: Please state your source of funding for this course, e.g. SELF FUNDING or EMPLOYER SPONSOR: Please answer YES or NO to confirm the following statements are correct: I have the ability to study at the appropriate academic level: (Degree level 6, or Masters level 7) I can demonstrate appropriate numeric skills: (e.g. GCSE in mathematics, or Learn Direct level 2 numeracy) I have identified a service need (in agreement with my employer) requiring me to undertake independent/supplementary prescribing training: I am able to provide evidence of assessed competence to take a history, undertake a clinical assessment and diagnose, before accessing this course: IF NO: I am willing to undertake another module concurrently to meet this requirement: 1
Please choose ONE of the following statements and enter details: I am currently enrolled on a recognised, credit-bearing consultation/assessment/diagnostics skills module, or a condensed consultation and assessment non-credited course: Please tell us the course title, start date and education provider I have already completed a recognised, credit bearing consultation/assessment/diagnostics skills module: Please tell us the course title, award date and awarding institution I have already completed a recognised condensed consultation and assessment non-credited course: Please tell us the course title, course date and education provider I can demonstrate, within my knowledge and skills framework, that I regularly undertake specialist assessments within my role: Please answer YES or NO to confirm that your employer has given commitment to the following: My attendance on this course: Provision of continuing professional development/updating: Provision of a Designated Medical Practitioner (DMP) as a mentor: Access to a prescribing budget and other necessary requirements for my prescribing practice: CONFIRMATION OF ABILITY TO DIAGNOSE IN AREA OF SPECIALITY TO BE COMPLETED BY YOUR EMPLOYER Please complete in BLOCK CAPITALS: Applicant name: Applicant job title: Area of speciality: Name of Line Manager: Name of employing Organisation: I confirm that the above named applicant has been assessed as competent to take a history, undertake a clinical assessment and diagnose. I am aware that registrants should not be put forward for the Non-Medical Prescribing course if they have not demonstrated the ability to diagnose in their area of speciality*. Signature of Line Manager: *NMC guidance states it should be possible to identify whether a registrant has these skills through Continuing Professional Development (CPD) reviews within the work place setting DECLARATION OF GOOD HEALTH AND GOOD CHARACTER I declare that my health & good character is of a standard that enables me to deliver safe and effective practice: DISCLOSURE AND BARRING SERVICES (DBS) CHECK To be completed by your employer: I confirm that the applicant named above has undertaken a DBS check within their current employment in the last 3 years. * If no, please attach copy of DBS application as evidence that this has been applied for 2
DESIGNATED MEDICAL PRACTITIONER (DMP) Has a Designated Medical Practitioner (DMP) been identified? (yes/no) A minimum of 78 hours (NMC/HCPC registered) or 90 hours (GPhC registered) of supervised practice with your designated medical practitioner (DMP) will be required. Your DMP must complete Mentorship Agreement on page 3 The DMP has a crucial role, which includes: Establishing a learning contract with the student Facilitating learning through critical thinking and reflection Providing dedicated time and opportunities for the student to observe how the mentor conducts a consultation/interviews the patient/carer and develops a management plan Allowing timefor the student tocarry out consultations and suggest clinical management plans and prescribing options which are discussed with mentor Allowing for the development and integration of theory and practice Giving opportunities for in depth discussion and analysis of clinical management plans using random case studies where patient care and prescribing behaviours can be discussed further Undertaking and verifying an Objective Structured Clinical Examination in practice with the student Assessing and verifying that by the end of course the student is competent to take on the prescribing role Please answer YES or NO to confirm the identified DMP has: Agreed to mentor me on this course: Been working as registered medical practitioner, with at least 3 years recent medical, treatment and prescribing responsibility for a group of patients/clients within the relevant field of practice Been working as a GP within a practice and is either vocationally trained or is in possession of a certificate of equivalent experience from the Joint Committee for Postgraduate Training in General Practice Certificate OR as a Specialist Registrar, Clinical Assistant or Consultant within an NHS Trust or other NHS employer? Agreed not to mentor more than 2 students at any one time: Gained the approval of the employer to undertake this mentoring role: Agreed to undertake a short preparation if required for the mentoring role, if they have not been a DMP for an independent/supplementary prescriber before: 3
PART 2 MENTORSHIP AGREEMENT SECTION A To be completed by applicant: I do not have any conflict of interest with my designated medical practitioner (You must let us know of any conflict of interest for example, if they are a relative or you are in a relationship with them other than a professional working relationship) Workplace contact details: (Address, phone, email) SECTION B To be completed by DMP: I have discussed the designated medical practitioner role with the above candidate and have the support of my employer to provide 12 days practice based training. I agree to undertake the role and to access the preparation provided. Professional regulatory body: Professional registration no: Designation and professional qualifications: Workplace contact details: (Address, phone, email) 4
PART 3 To be completed by ALL APPLICANTS EXCEPT PHARMACISTS (see PART 4) Specialist area of practice: No. of FULL years in current clinical setting: Please write a reflective account of approx. 500 words, explaining your rationale for entry to this course, including how you will use this qualification in your current role: 5
PART 4 To be completed by PHARMACIST applicants ONLY Continuing Professional Development (CPD) with dates: Please write a reflective account of approx. 500 words, explaining how these CPD activities have enabled you to maintain currency of your clinical, pharmacological and pharmaceutical knowledge: 6