STAFF USE ONLY Faculty of Health and Wellbeing Student Number New/Continuing SI updated letter Spreadsheet CPD code LBR CPD funding 2013/2014 - PRACTICE TEACHER PREPARATION Please indicate the Health Authority you are applying from: Health Education Yorkshire and Humber Health Education East Midlands 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 below Name of Trust/Private Organisation:... LBR Lead signature: Print Name: Email address: Date: Line Manager signature: Print Name: Email address: Date: APPLICANTS TO COMPLETE THE FOLLOWING SECTIONS: 1. Start Date Please tick your choice of start date - read note 2 of the application guidance before completing this section Start Date Choice Application Deadline September 2013 July 2013 2. Personal Details Title Date of Birth Sex Family Name First Names Home Address Email Address Work Address Previous Surname Home Tel Number Mobile Tel Number Work Tel Number For PG Office Use Only Student Number Funding Approved YES NO Signed
Academic Approval YES NO Signed 3. Professional Body Registration Registration Number Profession Expiry date The following section is to be completed only if you are a CURRENT STUDENT at Sheffield Hallam University, then go to section 8 4. Current Student Details Student Number Current Course The following sections are 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 5. Academic and Professional Qualifications and Credit including Short Courses/Training Courses/Continuing Professional Development Courses attended Please include details of BOTH qualifications and academic credit gained either at Sheffield Hallam University or elsewhere Read note 10 of the application guidance before completing this section Examining Body (Organisation responsible for your qualification) Subject (E.g. Nursing, Occupational Therapy etc) Type (E.g. Advanced Dip, BA, Credit only - state credit gained) Professional Qualification (E.g. RGN, RMN etc where appropriate) Year (Of Award)
6. Employment Details Please list your current post first, followed by other posts you have held Name and address of employer Post held 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. Continue on a blank sheet if necessary.
7. Disability and Support Needs Type of disability, please tick any that apply Dyslexia Deaf/hearing impairment Autistic spectrum disorders/ Asperger syndrome Multiple difficulties Hidden disabilities (Diabetes, Epilepsy, Asthma etc) Other Nature of support required: Blind/partially sighted Wheelchair user/mobility difficulty Personal Care Support Mental health difficulties Please specify Please specify 8. Criminal Convictions Do you have any relevant criminal convictions? Yes No 9. Equal Opportunities Monitoring Ethnic origin, please tick relevant option White Black Caribbean Black African Black Other Asian Other Please specify Pakistani Bangladeshi Chinese Indian Other 10. Religious Monitoring Religion, please tick relevant option Bah'ai Buddhist Christian Hindu Islam/Muslim Jew Pagan Prefer not to say Sikh Other 11. Nationality Details Country of birth Nationality Please specify
12. Declaration by 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 Health Education England. This includes information in relation to attendance, progression and achievement on modules. 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. Applicant's signature: Date: 13. 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 Email Phone If at any time you change your mind and would like the University to stop sending such information, please contact the Department 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.
The following sections are to be completed by the SUPERVISING PRACTICE TEACHER 1. Personal Details Full Name Organisation name and address Telephone Professional Body registration number Expiry date Signature Email address Date 2. Professional Details Please include dates Professional Qualifications Teaching/Mentoring Qualifications Date of most recent mentor/practice teacher update Recent professional development e.g. Conferences/study days/learning units to support the practice teacher role
The following sections are to be completed by the APPLICANT'S LINE MANAGER 1. Personal Details Full Name Position Name of clinical area Trust/private organisation Organisation Address Full telephone number Email address Extension I support (insert applicant's name) for the Practice Teacher Preparation module, and confirm that the above: (please tick the boxes) holds a current professional registration 1 and has at least two years relevant post registration experience has satisfactory CRB status, which has been undertaken in the last three years has developed his/her competence beyond registration has fulfilled the NMC criteria (if appropriate) as acting as a mentor will receive educational and organisational support to achieve the minimum of 30 days of protected learning time 2 will be supervised by an existing sign off practice teacher (SCPHN), or by an appropriate professional with the relevant teaching qualifications recognised by the NMC (SLAiP 2008) or HPC 3 will be able to act as a trainee practice teacher with appropriate learner(s) for the duration of the module will have access to an up to date satisfactory placement audit for their work area 4 See guidance notes at the end of this section In addition, I confirm that following successful completion of the programme, the Trust will: normally be able to enter the practice teacher on the local register as a practice teacher (SCPHN) or sign off mentor as appropriate. for SCPHN students, offer a period of preceptorship supported by an existing sign-off practice teacher, normally for a year, during which time further supervised sign-offs of students will be undertaken ensure continuing support from other experienced practice teachers when making final placement assessment decisions until the first triennial review
Signed by Line Manager: Date: Guidance notes for above NMC Part 1, 2 or 3 of the Professional Register, or registered as an allied health 1 professional on the Health Profession Council register Revised arrangements for the introduction of the practice teacher standard were introduced in April 2007 (NMC Circular 09/2007) which changed the time allowed to 2 complete a practice teacher qualification from six months to it being normally completed within six months Trainee practice teachers must be supervised by an existing sign off practice teacher 3 on at least one occasion for signing off proficiency of a Specialist Community Public health Nurse student at the end of their final placement (NMC Circular 27/2007) If no up to date satisfactory placement audit is available for the named applicant's 4 workplace, please contact the module leader* as soon as possible for the application to progress * Module Leader: Jill Gould, j.y.gould@shu.ac.uk 0114 225 2297