ࡱ> i ;bjbj \\3f< < 8 ah:"sss```````$bleR`s|sss`3` sj` s` sU#[IWW6u``0 aWek6el#[#[e[ss sssss``sss assssesssssssss< > z:  Non-Medical Prescribing Confirmation of Entry Requirements Thank you for applying for the Non-Medical Prescribing Course. The professional bodies you are registered with (NMC) have stipulated additional criteria in order for practitioners to enrol successfully onto this course. These include: Being a Level 1 registrant with the NMC Having been actively registered for at least one year Having the support of a Practice Supervisor Having the support of a Practice Assessor Having the support of practice placement area Having the required expertise in history taking, assessment and diagnostics In additional to the criteria listed above, the ý will also require the following: An electronic copy of a passport size photograph A copy of your statement of entry on the professional register Evidence of your ability to study at post-graduate level A copy of a recent DBS Enhanced check (please see Section 6 regarding this) A statement explaining any exceptional circumstances which warrant the need for your Practice Supervisor and Practice Assessor to be the same person, (if applicable). In such circumstances your statement should be supported by appropriate evidence. There are five sections to be completed within this document: Section 1About YouTo be completed by youSection 2About your Practice SupervisorTo be completed by you and signed by your Practice SupervisorSection 3About your Practice AssessorTo be completed by you and signed by your Practice AssessorSection 4Support from your practice placement areaTo be completed and signed by your line manager/manager responsible for your placement areaSection 5Funding information and Managerscommitment to support applicant To be completed by you (if self-funded)/ To be completed by your employer (if employer funded) To be completed by your Employer/ Trust Training Lead if HEE / Contract fundedSection 6Checklist of evidence of meeting entry requirements Please submit the completed form, and electronic copies of all the required supporting evidence as attachments, via email, to  HYPERLINK "mailto:Nhs-business-unit@beds.ac.uk" Nhs-business-unit@beds.ac.uk who are responsible for processing your application within the ý. Please note that following your letter/email offer of a place on the course, you will need to come to the ý to register for the course as part of the ýs normal enrolment process. At that time you must bring your passport, visa and birth certificates (as applicable), as well as the original (hard) copies of all the evidence that you have submitted with this form. Failure to do so may also result in a delay with in processing your registration on the course. Section 1 About You the Applicant Please provide the following information; Your Full Name (Print): Your NMC Registration (PIN) Number  Part 1 Are you currently the subject of any enquiry that may affect your professional registration? [Yes / No] Have you ever had restrictions imposed or been suspended by your professional council? [Yes / No] Have you ever commenced a non-medical prescribing course of study before? [Yes / No] If you have answered yes to any of these questions then, as well as submitting this form, please email  HYPERLINK "mailto:Richard.lumb@beds.ac.uk" Richard.lumb@beds.ac.uk (the Senior Lecturer of the course), as this will need to be discussed further before the ý will proceed with your application. Part 2 You are asked to read the following statements and confirm that you agree with them by adding your name to the bottom of the page: I confirm and can evidence that I have been a NMC registrant for at least 12 months (NMC Statement of Entry). I confirm that there is no conflict of interest between myself and the Practice Supervisor and Practice Assessor I confirm that I am not in (nor have I had) a close personal relationship with the Practice Supervisor or Practice Assessor. Where the Practice Supervisor and Practice Assessor are the same person, I have included additional documentary evidence with an explanation as to why there are exceptional circumstances that warrant such an arrangement. I confirm and include evidence of my ability to study at post-graduate level. I confirm that I am providing evidence of having undertaken a course of study in history taking, assessment and diagnostics (ý Transcript) or can provide evidence of an approved claim for Recognition of Prior Learning (RPL) or Recognition of Prior Experiential Learning (RPEL). Signed: Date: Section 2 Support from your Practice Supervisor Date: I hereby confirm my support for Student Name: to undertake the Non-Medical Prescribing Course. In particular: I confirm that I have read the Practice Supervisors Handbook and understand my responsibilities in supporting the student whilst in practice. I can confirm my eligibility to be their Practice Supervisor for the duration of the course. I am prepared to supervise them in practice for the duration of the course and will work closely with the Practice Assessor in order to help the student to achieve the necessary prescribing competencies What is your full name (Please print)? Please provide a sample of your signature in the box providedWhat is your GMC / NMC / HCPC / GPhC registration number? What is your work title and relationship to the student? What is your work address (for any correspondence)?What is your email address (please print): What is your contact telephone number?  Section 3 Support from your Practice Assessor Date: I hereby confirm my support for Student Name: to undertake the Non-Medical Prescribing Course. In particular: I confirm that I have read the practice assessor handbook and understand my responsibilities in supporting the student whilst in practice. I can confirm my eligibility to be their practice assessor for the duration of the course/module and include evidence of that with this form. I am happy to assess them in practice for the duration of the course and will work closely with the practice supervisor in order to help them achieve the necessary prescribing competencies. What is your full name (Please print)? Please provide a sample of your signature in the box providedWhat is your GMC / NMC / HCPC / GPhC registration number? What is your work title and relationship to the student? What is the date of your most recent Practice Assessor updateWhat is your work address (for any correspondence)?What is your email address (please print): What is your contact telephone number?  Section 4 Support from your Practice Placement Area (Page 1 of 2) This section is for your line manager to complete. If self-employed or an agency worker, then this can be a manager at the area in which you currently practising (and will use for the duration of the course). Where possible, this should not be your Practice Supervisor/Assessor. Date: I hereby confirm my support for Student Name: to undertake the Non-Medical Prescribing Course. In particular: I confirm that there is capacity in their work schedule to accommodate the (minimum) 78 hours protected time of supervised learning required as part of their practice placement. I confirm that the applicant has demonstrated in practice the appropriate skills to take a history, undertake a clinical assessment, and diagnose within their specialist field of work or has completed an appropriate course of study. I confirm that there is a clinical need within the registrants role to justify prescribing. I confirm that the applicant has sufficient knowledge to apply prescribing principles taught on the programme of preparation to their own area and field of practice, including where applicable, the assessment/diagnosis of children. I confirm that the applicant has demonstrated appropriate numeracy skills to perform drug calculations. Section 4 Support from your Practice Placement Area (Page 2 of 2) Date: Student Name: I confirm that the employing organisation has the necessary clinical governance infrastructure in place (including a Disclosure and Barring Service (DBS) check) to enable the registrant to prescribe once they are qualified to do so. I believe that the Practice Supervisor and Practice Assessor are a suitably qualified and experienced to undertake these roles in this area of practice. I am prepared to support any protected learning time agreed with the Practice Supervisor/Assessor and ensure that the student is able to attend all scheduled teaching sessions at the ý. What is your full name (Please print)? Please provide a sample of your signature in the box providedWhat is your GMC / NMC / HCPC / GPhC registration number? What is your work title and relationship to the student? What is the date of your most recent Practice Assessor updateWhat is your work address (for any correspondence)?What is your email address (please print): What is your contact telephone number?  Section 5 (1st part) Funding Information Please mark one option from below:  5.1 Self-Funded If self-funded do not fill this section 5.2 Employer Funded If employer funded, please fill below: EmployerFullName:. EmployerAddress:... .... EmployersEmailAddress: EmployersContactnumber:.. PurchaseOrdernumber:.. Date:.. Please provide sponsor letter on headed paper. This should contain: your name, employer, course you applied for, fee, name and signature of the person authorising funding. 5.3 Contract (HEE) Funded If contract funded, please fill below: TrustTrainingLeadauthorisation Pleaseprintname Trust Training Leads signature.... Date: . Please note: The ý will be unable to accept this application without correct authorisation. For all contract funded applicants please ensure the Trust training lead has signed the above. For all Employer funded applicants please provide sponsor letter from the employer. Both Contract funded and Employer funded applicants need to bring proof of funding on registration day, otherwise they will be not able fully register. Section 5 (2nd part) Managers commitment to support applicant I hereby confirm my support for the above named applicant to undertake this course and will support assessment of the applicants practice in the clinical setting where relevant. Where a nominee is on a Tier 2 Visa, I confirm that they are being supported to undertake this training and are being funded and I confirm that they can study at the ý. Please note: Applicants on a Tier 2 Visa need to bring supporting letter from the employer on Registration day, otherwise International Office will be not able to register them. Pleaseprintname.. JobTitle Managers Signature..... Date.. Section 6 Check list Section 1 Completed and signedSection 2 Completed, including PIN number, signed by Practice SupervisorSection 3 Completed, including PIN number, signed by Practice AssessorSection 3 Support from your Practice - Part B CompletedSection 4 Completed and signed by your practice area manager.Section 5 Funding authorisation completed and signed (if applicable)Evidence Do you have a copy of photo ID?Evidence Do you have a copy of any visas (if applicable)?Evidence Do you have a copy of your NMC Statement of Entry?Evidence Do you have a copy of your CPD/course certificates (Min L6)?Evidence For consideration of exceptional circumstances (If applicable)Evidence Do you have a copy of an acceptable Enhanced DBS Check? If not, will you be able to obtain an up to date copy before completion of the course? Please see below for details If you have entries on your DBS certificate, then please email the senior lecturer before you proceed with your application at  HYPERLINK "mailto:Richard.lumb@beds.ac.uk" Richard.lumb@beds.ac.uk. For your DBS check to be accepted: Regardless of your clinical role, all databases checks must have been requested, with the exception of the Section 142 educational checks. If you are using the online update service then a copy of your original certificate will be required as well. If you are not using the online service, then your certificate must be no more than 3 months old. If you are unable to meet any of these conditions, then a new certificate will need to be obtained. This must be presented before the first assessment is taken (week 15), if not ready in time for your application.     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