Faculty of Health and Wellbeing LBR CPD funding 2012/2013 - MENTOR PREPARATION FOR THE HEALTH PROFESSIONS (NMC APPROVED) Please indicate the health authority you are applying from Yorkshire and Humber Strategic Health Authority East Midlands Healthcare Workforce Deanery TRUSTS / PRIVATE ORGANISATION - PLEASE COMPLETE I confirm that the Trust named below has authorised the person named on this form to receive funding for the modules / courses listed above: Name of Trust / Private Organisation:... Signature of LBR Lead...PRINT NAME...Date:. Signature of Line Manager.. PRINT NAME. Date:. APPLICANTS - PLEASE COMPLETE 1. START DATE (Please tick your choice of start date) Staff use only Student Number.. New / Continuing Si updated letter Spreadsheet CPD code Start Date Choice 10 th September 2012 6 th November 2012 16 th January 2013 21 st March 2013 3 rd May 2013 The draft induction/workshop dates for 2012/13 are available please see the following link. http://www.shu.ac.uk/faculties/hwb/cpd/mentoring/ 2 TITLE (eg MR, MS, DR) DOB SEX (M/F) FAMILY NAME FIRST NAMES PREVIOUS SURNAME HOME ADDRESS POSTCODE WORK ADDRESS HOME TEL NO MOBILE TEL NO WORK TEL NO EMAIL ADDRESS
3. PROFESSIONAL BODY REGISTRATION: Registration Number:... Expiry date:... PROFESSION:... For PG Office use only Student Number The total fee for the above module(s) is Funding Approved YES NO Signed Academic approval YES NO Signed Have you been a student at Sheffield Hallam University before? Yes No If you are a current student please complete section 5 then go to section 11. If you are a new student please complete section 6 onwards. Section 5 - to be completed if you are a current student at Sheffield Hallam University I am a currently enrolled student. My Student Number is The course on which I am currently enrolled is now go to section 11 Section 6 - to be completed by all new students (this information will be used to assess your suitability for the named course or module/s for which you are seeking funding) 6 ACADEMIC AND PROFESSIONALQUALIFICATIONS AND CREDIT INCLUDING SHORT COURSES/TRAINING COURSES/CONTINING PROFESSIONAL DEVELOPMENT COURSES ATTENDED Please include details of BOTH qualifications and academic credit gained either at Sheffield Hallam University or elsewhere. This section must be fully completed to avoid enrolment queries. Examining Subject Type Grade Body (Organisation (e.g. Nursing, (e.g. Advanced Dip, (e.g. 2.1,2.2. 3 rd, responsible for your Occupational BA, Credit only - qualification) Therapy etc) state credit gained) pass) Professional Qualification (e.g. RGN, RMN etc. where relevant) Year/Month (of award)
7 EMPLOYMENT EMPLOYMENT Please list your present post first, followed by other posts you have held. Names and addresses of employers Post held 8 Further Information Please give further information in support of your module/ course application. Include reasons why you wish to access the module/s or course listed giving information regarding Continuing Professional Development you have already undertaken, highlighting relevant work experience and in service training.
9. SUPPORT FROM LINE MANAGER (Please ask your line manager to complete this section) Please print in capital letters Full name Position Name of clinical area Trust/ private organisation Address Postcode Full telephone number, including extension E-mail I support (insert applicant's name)... for the Mentoring and Facilitating Your Own and Other Professions module, and confirm that the above: (please tick the boxes) Holds current professional registration CRB status is satisfactory (if appropriate) Will be released for the relevant workshops and study days and supported to achieve the 5 days of protected learning time 1 Will have protected and agreed access to internet facilities Will have access to a named supervisor in practice who is identified on the live register of mentors and has been updated in the previous 12months (additional requirements for nurses and midwives only) 2 Will be able to act as a mentor with a learner for at least 4-6 weeks 3 Will have access to an up to date satisfactory placement audit for their work area 4 Please tick and signed by line manager level 5 (Diploma) level 6 (Degree) Signed by line manager...date:... 1 For registered nurses and midwives the NMC Standards to support learning and assessment in practice (2006) require that students undertake mentor preparation programmes that are a minimum of 10 days, of which at least 5 days are protected learning time. Students on the module are required to evidence achievement of these 10 days and attend all of the workshops unless they are prevented from doing so by illness or some other domestic or personal emergency. 2 Nurses and Midwives are required to have experience in mentoring a student under the supervision of a qualified mentor (NMC 2006). The applicant will require a support from a qualified mentor, already on a live register in their work place, for the duration of this module. Please contact the module leader* with any queries. 3 All midwifery mentors will have met the additional criteria to be a sign-off mentor as part of their preparation programme (NMC 2006), and therefore should be in a position to mentor students passing through an appropriate progression point as agreed by the NMC Midwifery Committee (2007) 4. If no up to date satisfactory placement audit is available for the named applicant's workplace, please contact the module leader* as soon as possible for the application to progress *Module Leader: Margaret Dunham/Cate Johnson. Email: m.dunham@shu.ac.uk or c.e.johnson@shu.ac.uk
10. Disabilities and support needs Type of disability Dyslexia Deaf/hearing impairment Autistic spectrum disorder/asperger syndrome Multiple difficulties Hidden disabilities (diabetes, epilepsy, asthma etc) Blind/partially sighted Wheelchair user/mobility difficulty Mental health difficulty Personal Care Support please specify Other please specify Nature of support required 11. Criminal Convictions Do you have any relevant criminal convictions? Yes No 12. Equal opportunities monitoring Ethnic origin White Black Caribbean Black African Black Other Indian Pakistani Bangladeshi Chinese Asian Other Other please specify Religion (please tick the relevant option) BAH'AI BUDDHIST HINDU JEW ISLAM / MUSLIM SIKH OTHER PREFER NOT SAY NONE PAGAN CHRISTIAN / C&E / ROMAN CATHOLIC Country of birth (please specify) Nationality (please specify)..
13. DECLARATION All Applicants I confirm that, to the best of my knowledge, the information given in this form is correct and complete. I understand that any offer of a place on the above course is subject to my acceptance of the University's terms and conditions which I have received, read and understood. I agree to the disclosure of my data to my employers and the Strategic Health Authority I also confirm that I am able to send and receive e-mail and able to check for receipt of emails 2-3 times per week. I confirm that I can access the internet using a computer made available to me at work or outside work. If the computer that I will mainly use is at work I confirm that I have made agreements with my manager about protected access time in order to carry out my studies. In addition I confirm that I am confident in the following necessary IT skills to complete the module as outlined in the criteria below: Ability to use the internet, e.g., access websites, use search engines, download files to my PC, etc. Ability to use word processing packages Please note that it is essential to make sure that the computer you are using has effective virus protection. Application to the module also confirms agreement to the following compulsory requirement. Log on to Blackboard a minimum of 2-3 times per week to read and contribute meaningfully to discussion forums during the module I understand that the above requirement is a compulsory part of the programme.. Applicant's Signature: Date:.. Sheffield Hallam University use only Approved by Course Leader... Date... Data Protection Statement The information you supply on this form will be used by Sheffield Hallam University in accordance with the Data Protection Act 1998 and other applicable legislation. The University will use the information to process your application and to provide any relevant further information by post, e-mail or text. It will also be used to support the University's marketing and market research activities. Please tick if you do not wish to receive further information by Post Text E-mail Phone If at any time you change your mind and would like the University to stop sending such information, please contact the Dept. of Marketing, Sheffield Hallam University, Sheffield S1 1WB or e-mail marketing@shu.ac.uk. The University does not share the information you have provided with any other third party, except research agencies which assist with or carry out research and service providers who deliver e-mail and text messages on the University's behalf. The University ensures that such agencies will also handle personal data in accordance with the Data Protection Act.