ࡱ> !$ ] 09bjbj:: 4,X*\X*\0  NNNNNbbb8fb4fj|4~4~4~4~4~4~4$c7:x4N4NN44$$$NN|4$|4$$V,@-7=@o,- h44048-x:! :-:N-hJ$f<?44"4: > :   Continuing Professional Development Module Application Form Use this form to register for individual study modules. There is a different application form for entry to Degree and MSc programmes. Applicants for modules that lead to professional registration are required to provide supplementary information on a separate sheet. Please contact us if you do not have the required supplementary details form, and are applying for a place on one of the following: Independent & Supplementary Prescribing Injection Therapy An application form for a place on a BSc or MSc programme is available from the Admissions Department -  HYPERLINK "mailto:PGapply.FHS@soton.ac.uk" PGapply.FHS@soton.ac.uk Prior to submission, please check that: All relevant sections are fully completed Your Manager has signed Part G The form has been countersigned by an authorised NHS signatory if your place is to be funded through a pre-purchased HEW funded place You have enclosed a completed Module Payment Form if necessary. If the information provided is incomplete the application form will be returned to you, which will delay your registration and may result in a lost place. The completed form should be returned to: Continuing Professional Development Faculty of Health Sciences Student Admin Level 3 Nightingale Building - 67 TV Highfield Southampton SO17 1BJ Continuing Professional Development Application form for entry to individual modules of study Have you undertaken study at the TV in the past? Please tick which: Yes ( No ( If Yes, please state your University ID number here: (((((((( Part A - Personal details to be completed by applicant Family Name First Names Title Date of BirthMaiden/previous nameMaleFemaleHome address Town PostcodeTelephone Number Home:Mobile:E-mail address  Part B - Work details to be completed by applicant Name of Employing Trust/Organisation  Your Work address Ward Address Post Code Telephone Number (including extension) E-mail address  Current Job Title and Grade  Part C - Professional details to be completed by applicant Which professional body are you registered with? Nursing & Midwifery Council ( Health Care Professions Council ( Other (Please state)  Please state your registration number: ((((((((((((( If applicable please list which parts of the NMC Professional Register you are on (See guidance notes at the end of this form) PART*(1-3) DATE OF REGISTRATION (Month/Year) ACTIVENON-ACTIVEDATE RE-REGISTRATION DUE (Month/Year) PRACTICE SPECIALTY  We are required to ask the following questions for special requirements, University regulations, and statutory reporting purposes. Part D Additional Needs See guidance notes at end of form. Please tick the relevant box if you have any of the following disabilities/medical conditions ((02) Visual impairment((07) Unseen disability (eg, diabetes, epilepsy or asthma)((03) Hearing impairment((08) Multiple disabilities((04) Mobility impairment((10) Autism spectrum disorder((05) Personal care support((11) Specific learning difficulty (eg, dyslexia)((06) Mental health issues((96) A disability not listed above Are you receiving Disabled Student Allowance from your funding body? ( Yes ( No ( Awaiting outcome of claim If you have a criminal conviction which you are required to declare please tick this box (Please see the guidance notes for further information) ( Part E - Module registration details MODULE CODEMODULE TITLESTART DATETICK IF MODULE IS PART OF PROGRAMME PATHWAY Registration for a module of study assumes that you will participate in the assessment for that module. If the module(s) you are undertaking has/have been purchased for you by your employer and they wish to exempt you from this requirement we will need written confirmation from your manger/employer that this is the case. Regardless of this, failure to submit any assignment associated with the module will be considered by the Faculty to be a fail outcome. If you are not funded through a Health Education Wessex (HEW) funded place you must complete the enclosed payment form and return it with this application. Authorisation of Allocation of Contracted Place Authorised Signature Name in Block Capitals Comments  HEW funded place: Yes ( Please tick which: Preferred Provider ( Non Preferred Provider ( HEW ALPS place: ( Other Source of Funding (please specify) ( ___________________________ Part F - Declaration by Applicant By submitting this application form: I declare that the information I have provided is accurate and that no material in formation has been omitted. I consent to the University processing this application. I agree to undertake a Disclosure and Barring Service screening check (if required), to provide evidence when requested and to meet cost implications if necessary. I understand that information regarding attendance and module outcomes will be communicated to my Sponsoring Trust. I agree to abide by the Universitys rules and regulations if I am accepted onto a module. Signed (Applicant) Date  Part G - to be completed by Manager Declaration by manager I confirm that: (Applicants Name )  Is an employee. Occupational health clearance has been conducted satisfactorily with an acceptable outcome (and completed within the last four months for a non-NHS employee). Disclosure and Barring Service screening or equivalent has been satisfactory (and completed within the last four months for a non-NHS employee). Assessment will be undertaken in such an environment according to the requirements of the TV Faculty of Health Sciences clinical audit requirements. The applicant is supported for release to the specific education and training as agreed with manager. The applicant will be given the opportunity for supervised clinical practice to meet course requirements. The fees will be met as detailed in Part E or the Module Payment Form. Required to take Assessment for Credit. Attendance is a Result of Appraisal Yes ( No ( Date: Managers Signature: Name in Block Capitals: Telephone No: CONFIDENTIAL: ETHNIC ORIGIN SURVEY CONFIDENTIAL: ETHNIC ORIGIN SURVEY The University is committed to creating an inclusive environment where students are treated in a fair and non-discriminatory way and differences are respected. The information you provide in this survey will help us to monitor progress at increasing diversity in our student community. All students applying to universities in the UK are asked to complete an Ethnic Origin Form. This information is required by the Higher Education Statistics Agency and is used for monitoring purposes. It is NOT used for admissions purposes. Upon receipt, the form is kept separate from your application and is not seen or made known to anyone considering your application. Please include details of the course you have applied for and also print your name before signing the form. Please return the form with your application. Please read the list below and tick the appropriate box that you feel most nearly describes your ethnic origin. WhiteMixed ((10) White((41) White & Black Caribbean((14) Irish Traveller((42) White & Black African((43) White & AsianBlack or Black British((49) Other Mixed background((21) Caribbean((22) African((80) Other Ethnic background((29) Other Black background((98) I decline to say Asian or Asian British((31) Indian((32) Pakistani((33) Bangladeshi ((34) Chinese((39) Other Asian background I consent to the University processing this information for monitoring purposes on the understanding that it will not be disclosed to any person considering my application for admission. Full name ___________________________________ Signature ____________________ Module of TV ___________________________________ Date ____________________ Parts of the Nursing and Midwifery Council professional register Part 1 - Nurses This is divided into two Sub-parts - Sub-part 1 for all Level 1 nurses and Sub-part 2 for all Level 2 nurses Sub-part 1Sub-part 2 Field of PracticeRegistration Entry CodeField of PracticeRegistration Entry CodeAdultRN1, RNAAdult RN2Mental HealthRN3, RNMHMental HealthRN4 Learning Disabilities RN5, RNLDLearning Disabilities RN6ChildrenRN8, RNCChildren RN7FeverRN9 Part 2 - Midwives Field of practiceRegistration entry code MidwiferyRM Part 3- Specialist community public health nurses Field of practiceRegistration entry codeSpecialist Community Public Health Nursing- HV RHVSpecialist Community Public Health Nursing- SNRSN Specialist Community Public Health Nursing-OH ROHSpecialist Community Public Health Nursing- FHNRFHN Recorded qualifications PrescribingV100 Community Practitioner Nurse Prescriber V200Nurse Independent PrescriberV300Nurse Independent/Supplementary PrescriberSPANSpecialist Practitioner - Adult NursingSPMH Specialist Practitioner - Mental Health SPCNSpecialist Practitioner - Childrens Nursing SPLDSpecialist Practitioner - Learning Disability NurseSPGP Specialist Practitioner - General Practice NursingSCMH Specialist Practitioner - Community Mental Health Nursing SCLDSpecialist Practitioner - Community Learning Disabilities NursingSPCCSpecialist Practitioner - Community Childrens Nursing SPDNSpecialist Practitioner - District Nursing  Guidance Notes Additional Needs We are committed to delivering services and support that will allow every student to fulfil their potential in an accessible learning environment. The information you provide in this section helps us identify whether we can make any adaptations to meet your needs. We encourage you to declare any condition you may have, even if you do not require any special arrangements or facilities. Completing this section will not in anyway influence the assessment of your academic qualifications. Once an academic assessment of your application has been made, the Universitys Disability Service may invite you to visit the campus to discuss particular requirements. Criminal Convictions You must tell us about any criminal convictions, including spent sentences and cautions (including verbal cautions) and bind-over orders, UNLESS your Manager has signed Part G to confirm that Police Screening has been satisfactory. In this case you may need an enhanced disclosure document from the DBS or Scottish Criminal Record Office Disclosure Service. The University will send you the appropriate documents to complete. If you are convicted of a relevant criminal offence after you have applied, you must tell us. We will then ask you for further details. Further information Ethnic Origin Form Please complete the separate Ethnic Origin Form. This information is used to monitor the Universitys progress at increasing diversity in our student community. This information is not used when making a decision about whether to offer you a place. The information is kept separate from your application, and is not seen or made known to anyone considering your application. Data Protection Information collected from applicants will be used only for the purposes for which it was collected and to support the Universitys central activities (mainly teaching and research). It also supports procedures which underpin activities such as admissions, enrolment, accommodation, examinations, alumni activities, and helps us to compile records and statistics. The University may be called upon to cooperate with the police in crime investigation and with certain other public authorities. In such circumstances, personal data may be released. You should be aware that information about your enrolment, attendance and progress at the University might be passed to your employer and to the immigration and Nationality Directorate of the Home Office for purposes connected with immigration.     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