SCHOOL OF NURSING ND MIDWIFERY NON-MEDICL PRESCRIBING PPLICTION FORM Before completing this application form please read the notes on the back page. Please complete all sections of this form using a black ballpoint pen or black type in BLOCK CPITLS. Incomplete forms and enclosures may delay the processing of your application. Form C-NUMI-NMP1. Proposed Programme of Study (see note 1) Programme Name : Bachelor of Nursing (BN) Bachelor of Midwifery (BM) (Complete if applying for full programme) Postgraduate Masters in dvanced Practice (MSc) Stand lone Module Name(s): Degree Level (SCQF Level 9) (Select the required level) Masters Level (SCQF Level 11) Entry Month (tick one) : September January Mode of ttendance : Part-time Full-time Entry Year : B. Previous Contact with Dundee (see note 2) re you currently, or have you previously, been a student of the University of Dundee? Yes No Matriculation or pplication No. Have you previously submitted an application to the University? Yes No C. Personal Details (see note 3) Surname / Family Name Title : Mr / Miss / Ms / Mrs Male / Female (Please circle) First / Given Name(s) Date of Birth (dd / mm / yyyy) d d / m m / 1 9 y Y Name by which you would like to be known: Previous Surname: Permanent Home ddress Employment/Other ddress (or stamp) City / Zipcode Country s (with Country and rea Code) Tel: Mobile: City / Zipcode Country Telephone & (with Country and rea Code) Which is your correspondence address (letters from the University will be sent to this address) : Home address Employment/Other address Passport Number: Nationality: Country of Birth: rea of Permanent Residence: Tel: Fax: Local Education uthority (UK only): If you have given a home address in the UK/EU, how long have you been resident in the UK/EU? Years. FOR UNIVERSITY USE ONLY Note UO SIG 1: Date: SIG 2: Date: CO R Start Date: Date Received:
D. Funding Details How will your programme fees be met? Wholly by Employer Partly by Employer, partly by yourself Wholly by yourself Other. Please specify Note : if you are not self-funded, it is in your interests to ensure that arrangements are confirmed with your funder at an early stage. E. dditional Information (see note 4) 1 Disability : The University encourages applications from students with disabilities and special needs and is keen to provide appropriate support for study and/or accommodation. If you have a disability, special needs (including dyslexia) or medical condition, please tick the appropriate box and enclose further details where necessary: 0. No disability or awareness of additional support requirements T. utistic Spectrum Disorder or sperger Syndrome 1. Specific learning difficulty (e.g. dyslexia, discalculia) 6. Mental Health difficulties 2. Blind or partially sighted 7. Unseen disability (e.g. diabetes, epilepsy, heart condition) 3. Deaf or Hearing impairment 8. Multiple disabilities two or more of the above 4. Wheelchair user or Mobility difficulties 9. Other disability please provide information on separate sheet 2 a) re you registered with the Nursing and Midwifery Council / Health Professions Council? Yes No b) NMC PIN / HPC Registration Number c) Expiry date F. English Language (see note 5) ll students studying at the University of Dundee must have an English Language qualification equivalent to GCSE/Standard Grade English Language. Please indicate whether English is: (tick only one) a) Your first language b) Your main language for education c) Learnt as a foreign language UK-based English Language qualifications that satisfy the English Language requirement are, for example, O-grade, standard grade, Higher, dvanced Higher, Intermediate 2, CSYS, O-level, O-level, S-level, -level, GCSE, and Communications 4. Indicate any UK based qualifications that you have in English Language below: Exam type and subject (e.g. O-grade English Language) Score/Grade Date of ward University/College/School attended Indicate any internationally recognised qualifications gained as proof of English Language level and score/grade achieved (e.g. IELTS, TOEFL, Cambridge, IGCSE, International O-Level). You must have completed these exams and received the results prior to matriculation. You must attach a certified copy of your certificate. Test type (e.g. IELTS) Score/Grade Date of Test IELTS TRF Number (if applicable) Further information about English Language requirements can be obtained at http://www.dundee.ac.uk/admissions/international/english.htm
G. Current Employment Details (see note 6) Name of Current Employer Current Employer ddress Present Place of Employment Position Held : Do you work : Part-time v Full-time v Number of hours worked per week? hours Number of years in present post? years What is the nature of your current post? (Note : you must clearly show that you have a minimum of 3 years Post Registration experience. NMC registered applicants must indicate that the year immediately preceding this application has been spent in the clinical field in which you intend to prescribe.
H. Line Manager and Designated Medical Practitioner Details Current Line Manager Name Position and Grade Location ddress Line Manager s Designated Representative (if appropriate) Name Position and Grade Location ddress Line Manager pproval & Signature Line Managers or Designated Representatives should complete Form SOSLM3 which can be found at the end of this form after the Notes section. Designated Medical Practitioner (Mentor) - IMPORTNT : Mentors should read NOTE 6 at the end of this form for details of the role and responsibilities of the designated medical practitioner. Name Position and Grade NHS/Independ Sector Base & Specialty Work base ddress Designated Medical Practitioners must meet the following criteria as stated in NPC document (see NOTE 6) Tick as appropriate The Designated Medical Practitioner (DMP) must be a registered medical practitioner who : Yes No Has formally had at least 3 years recent clinical experience for a group of patients/clients in the relevant field of practice is within a GP 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 is a specialist registrar, clinical assistant or a consultant within an NHS Trust or other NHS employer. has the support of the employing organisation or GP practice to act as the DMP who will provide supervision, support and opportunities to develop competence in prescribing practice Has some experience or training in teaching and/or supervising in practice normally works with the trainee prescriber. If this is not possible (such as in nurse-led services or community pharmacy), arrangements can be agreed for another doctor to take on the role of the DMP, provided the above criteria are met and the learning in practice relates to the clinical area in which the trainee prescriber will ultimately be carrying out their prescribing role Signed: Date:
I. Work Experience (see note 6) Details of Work Experience to date : Date From To Part-time / Full-time Paid / Unpaid Organisation Employer Position Held and Responsibilities J. Qualification Details (see note 7) Please list below relevant qualifications obtained at university/college, starting with the most recent. University/College ttended Start Date Completion Date ward Obtained including Level (e.g. B Level 10) Subject/Programme/Module title and Grade/Score (as appropriate)
K. Other relevant academic or professional qualifications (see note 8) Please list below any other relevant academic or professional qualifications, including qualifications in progress, starting with the most recent. warding Body ward Title/ Level / Number of Credits (e.g. RN) Date of ward/registration L. Credit Claim Details (see note 9) Elements of prior study/learning (e.g. OU courses, modules taken elsewhere at an appropriate level, etc) may be used to seek specific credit or exemption in relation to a full Programme, but not an individual stand alone module. maximum of two modules only will be accredited towards a programme. Please indicate below if you wish to apply for ccreditation for Prior (Experiential) Learning (P(E)L): I wish to apply for ccreditation for Prior Certified Learning (PL) I wish to apply for ccreditation for Prior Experiential Learning (PEL) Information regarding credit claims can be obtained in two ways. Please indicate below how you wish to do this: Download an application form and guidance notes from our website at www.dundee.ac.uk/nursingmidwifery Be sent an application form and guidance notes to my correspondence address Note that evidence in support of such claims will be required on application of P(E)L. M. ccess to Computer and Internet Facilities In order to gain access to programme/ module information, it is essential to have access to a computer and to be able to access the internet. Do you have access to a computer? Yes No Can you access the Internet? Yes No Please contact the Programme Leader if you do not have access to a computer and/or the Internet.
N. Personal Statement in Support of pplication (see note 10) Please tell us why you are applying to this Programme/ module, why you are suited to it, and what you hope to gain from it. This should include an indication of the clinical need for non-medical prescribing in your area of practice. Continue on an extra sheet, if required. O. Referee Details (see note 11) Please provide the contact details of two referees who should be able to comment on your interest, ability and commitment to your profession and to your professional development. You should ensure that each of your referees receives one of the reference forms that are enclosed with the application form. Instructions for the completion and submission of the reference forms are given. Referee 1 Name Occupation/Position Relationship to applicant ddress Referee 2 Name Occupation/Position Relationship to applicant ddress
P. Source of Information on this Programme/ Module How did you hear about this Programme/ module? (Please tick one) School of Nursing & Midwifery Prospectus/Mailshot Colleague School of Nursing & Midwifery/University of Dundee Website Current/Former Student University of Dundee CPD/Distance Learning Prospectus Family or Friend Learn Direct Employer NMC / Health Professions Council gent/gency please specify below Media dvert please state which one below Other please specify below Q. Supporting Documents (see note 12) You are required to provide photocopies of your Qualification Certificates. We reserve the right to ask to have sight of the original documents. ll applicants are required to provide a passport-sized photograph, which will be used to produce a Student ID card for you. Please tick the relevant boxes below to indicate which copies of documents you have enclosed with your completed application form. English Language Certificate(s) College/University Transcripts / Certificates Certificate of Training / Diploma of Higher Education Copy of NMC/ HPC/ other Professional Body Registration Card passport photograph (see note 12 for more details) More information on your disability, if applicable If self-employed - Enhanced Disclosure Scotland check and recent positive health check Other give details R. Declaration (see note 13) I certify that the information given on this form is true, complete and accurate. If I am admitted to the University, I undertake to observe the University s Ordinances and Regulations and to ensure payment of tuition fees and other financial liabilities to the University. Data Protection ct 1988. The personal information provided by you on this form will be used for the purposes of processing your application, monitoring your student career, and for general market research. For market research, the information will be used to produce aggregate statistics and will not be used in ways that identify any individual. The information you provide will be used for no other purpose. In signing this form you consent to the information which you provide being held and processed by the University of Dundee, in electronic and manual formats, for the purposes specified above. I accept that information about my progress and outcome on the Programme may be shared with my employers if they are supporting my studies by giving study time and/or funding. I agree to inform the University immediately if I decide not to proceed with my application. Once you are matriculated, may we release your contact details to other students on the Programme/ module? Signed: Yes Date: No Please return this form to : Post Registration/Postgraduate School of Nursing and Midwifery University of Dundee 11 irlie Place Dundee DD1 4HJ Scotland. UK For further information, contact: Student and Programme dministration Tel: +44 (0)1382 388534 Fax: +44 (0)1382 388533 : nm-spa@dundee.ac.uk Web: www.dundee.ac.uk/nursingmidwifery
Proposed Programme of Study note 1 Programme information about these programmes is available in our prospectus or on our website: www.dundee.ac.uk/nursingmidwifery Entry Month this is the calendar month in which you wish to start the programme, e.g. September or January Mode of ttendance tick either full-time (undertaking two modules of the Programme concurrently), or part-time (undertaking the Programme over a period of five years). Stand lone modules are part-time. Entry Year this is the calendar year in which you wish to start the programme, e.g. 2007, 2008, 2009, etc. Previous Contact with Dundee note 2 Please provide this detail, if appropriate, as it will help us to retrieve your previous applicant/student record, and add this application quickly. Personal Details note 3 Surname/ Family Name and First/Given name(s) please make sure that you write your family name in full and include all of your given names. It should be written the same way that your name is written in your current passport, driving licence, or other formal document. Do not shorten or abbreviate any of your names. Use Name by which you would like to be known to record shortened or alternative names. Date of Birth please write this in the order of day / month / year (e.g. 19/07/70 = 19 th July 1970) Previous Surname/Maiden name provide this if your surname is different from that on your birth certificate or supporting documentation Correspondence ddress this will be the address we will use to write to you about any decisions made on your application. Please notify us if you change your permanent home, additional or work address. please write this very clearly, as it is a quick way of contacting you about your application. Passport Number this is only required for applicants who have a non-uk passport rea of Permanent Residence if UK-based, enter the county within the UK; if non-uk based, enter the country. dditional Information ll information is kept in accordance with the Data Protection ct 1988 note 4 Disability and Special Needs Please mention any disability or medical condition, so that where possible appropriate support and resources can be arranged. The University encourages applications from students with disabilities and special needs. English Language note 5 Programmes at the University are taught in English, and so a minimum level of English Language is required. Current Employment Details/ Work Experience note 6 Please provide details of duties and responsibilities of current and previous work experience. Continue on a separate sheet, if required. Section H : Designated Medical Practitioners (Mentors) for the Non-Medical Prescribing Module must meet the eligibility criteria as defined on page 7 of the National Prescribing Centre (NPC) document Training Non-Medical Prescribers in Practice found at www.npc.co.uk/pdf/designated_medical_practitioners_guide.pdf Qualification Details note 7 Please give full details of college/university, post registration/postgraduate qualifications completed to date, starting with the most recent. Where possible, list the subjects and level/grades obtained. Continue on a separate sheet, if required. Other relevant academic or professional qualifications note 8 Please provide full details of other relevant qualifications including any that are pending (say when you expect to receive the results). You may be given a conditional offer based on the results of pending exams. Credit Claim Details note 9 Indicate whether you wish to claim specific P(E)L credit within this programme. The amount of specific credit which may be awarded will depend on how closely the prior learning relates to the proposed programme of study. Specific credit will normally be given only for learning undertaken within the last 5 years. maximum of two modules only will be accredited towards the programme. Personal Statement note 10 lso include in this section anything else that has not been covered elsewhere in the form. Non-Medical Prescribing Module applicants are required to clearly identify the clinical need for prescribing in their area of practice. It is also compulsory that the number of years spent in the clinical area you will be prescribing is indicated. Referee Details note 11 Please give contact details of 2 referees who will support your application. You should ensure that each of the referees receives one of the reference forms that are enclosed. If these are missing, contact 01382 388534 to request copies. Please note that it is the responsibility of the applicant to ensure that the references are returned along with the completed application form. Supporting Documents note 12 Ensure that your passport photograph is in colour and that it is of your face, head and shoulders. On the back of the photograph, please write your full name and sign the back to confirm that this photograph is a true likeness of you. If providing other supporting documentation, ensure that your name is clearly written or visible on each additional sheet. We reserve the right to ask to see other supporting documentation at a later date if necessary. Declaration note 13 You must sign the application form. By signing the form, you are declaring that, to the best of your knowledge, you have included correct, complete and accurate information. The information will be used for processing your application. What happens next? note 14 We will acknowledge receipt of your application soon. If your application is complete we will then write to you with our decision, which will be one of the following: an unconditional offer of a place; a conditional offer of a place (requiring you to meet certain requirements first); a rejection. If the application is incomplete, we will not process your application further until we receive the necessary documentation.
. pplicants Details SCHOOL OF NURSING ND MIDWIFERY Form SOSLM -3 STTEMENT OF SUPPORT FROM LINE MNGER Completion of this form by a Line Manager is an essential requirement for the Non-Medical Prescribing module only. Please complete all sections of this form using a black ballpoint pen or black type in BLOCK CPITLS First / Given Name(s) Date of Birth (dd / mm / yyyy) d d / m m / 1 9 y y Surname / Family Name Title : Mr / Miss / Ms / Mrs Male / Female (Please circle) B. Support Requirements Practitioners undertaking the Non-Medical Prescribing module are required to commit a considerable amount of time and effort to the learning in practice component. This commitment involves the practitioners using a proportion of their contracted working hours. Managers and employers must be prepared to support the practitioner by releasing them from a proportion of their usual duties and responsibilities. The theory days are based at the University and attendance is compulsory. Learning in Practice takes place within the students workplace. However, students must be given the freedom to achieve competencies associated with the module. This will require them to spend time with their Designated Medical Practitioner and to gain experience, which may be outwith their usual practice, such as spending time in other wards or departments or with other professionals and agencies, e.g. with pharmacists. ll students will therefore require a minimum agreed facilitated learning time equivalent to 12 days - mutually agreed between student, designated medical practitioner and line manager. This will be used to undertake short placements or focused learning visits to achieve the learning outcomes and competencies for the module. C. Line Manager s Statement of Support In addition to the support requirements in B above, the following are required : 1. The applicant is assessed as competent to take a history, clinical assessment and diagnose within their clinical speciality. 2. There is a clinical need to justify prescribing. 3. The applicant has sufficient knowledge to apply prescribing principles taught in the module to their own area of practice. 4. The applicant is able to demonstrate appropriate numeracy skills. 5. Confirmation that the applicant has a current Enhanced Disclosure Scotland check* (see note below). 6. Confirmation that the applicant has been subject to positive health checks* (see note below). * Note: if self-employed, you must provide evidence. I agree to provide appropriate support to allow the candidate to meet the module requirements described in B and confirm items 1-6 in C. Name: Signed: Date: This form should be returned with the candidate s application form to the address given on the application form.
1. pplicants Details SCHOOL OF NURSING ND MIDWIFERY REFERENCE IN SUPPORT OF DMISSION NON-MEDICL PRESCRIBING This form should be handed to the referee for return to the address given at the bottom of this page. Please complete all sections of this form using a black ballpoint pen or black type in BLOCK CPITLS Form T-NUMI-REF3 First / Given Name(s) Date of Birth (dd / mm / yyyy) d d / m m / 1 9 y y Surname / Family Name Title : Mr / Miss / Ms / Mrs Male / Female (Please circle) 2. Proposed Programme of Study Module / Programme Name : (Use exact title with subject designation if relevant) 3. Referee Details Referee Name Occupation/Position Relationship to applicant Contact ddress 4. Referee s Statement Please provide a reference for the above candidate, indicating his/her suitability for postgraduate study. Continue on an extra sheet, if required. Signed: Date: PLESE ENSURE THT THIS FORM IS RETURNED DIRECTLY TO : Post Registration / Postgraduate Office, School of Nursing and Midwifery, University of Dundee, 11 irlie Place, Dundee, DD1 4HJ, Scotland. UK OR RETURNED TO THE PPLICNT IN SELED SIGNED ENVELOPE. THNKS.
1. pplicants Details SCHOOL OF NURSING ND MIDWIFERY REFERENCE IN SUPPORT OF DMISSION NON-MEDICL PRESCRIBING This form should be handed to the referee for return to the address given at the bottom of this page. Please complete all sections of this form using a black ballpoint pen or black type in BLOCK CPITLS Form T-NUMI-REF4 First / Given Name(s) Date of Birth (dd / mm / yyyy) d d / m m / 1 9 y y Surname / Family Name Title : Mr / Miss / Ms / Mrs Male / Female (Please circle) 2. Proposed Programme of Study Programme Name : Use exact title with subject designation as relevant 3. Referee Details Referee Name Occupation/Position Relationship to applicant Contact ddress 4. Referee s Statement Please provide a reference for the above candidate, indicating his/her suitability for postgraduate study. Continue on an extra sheet, if required. Signed: Date: PLESE ENSURE THT THIS FORM IS RETURNED DIRECTLY TO : Post Registration / Postgraduate Office, School of Nursing and Midwifery, University of Dundee, 11 irlie Place, Dundee, DD1 4HJ, Scotland. UK OR RETURNED TO THE PPLICNT IN SELED SIGNED ENVELOPE. THNKS.