Learning beyond registration



Continuing Professional DevelopmentModule Application Form Use this form to register for individual study modules. There is a different application form for entry to Degree and MSc programmes. Applications for modules that lead to professional registration are required to complete 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 TherapyAn application form for a place on a Degree or MSc programme is available from the Admissions Department - PGapply.FHS@soton.ac.uk Prior to submission, please check that: ? All relevant sections are fully completed ? Your Manager has signed Part H ? The form has been countersigned by an authorised NHS signatory if your place is to be funded through a pre-purchased NHS contract 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 DevelopmentFaculty of Health Sciences Student Admin – Level 3Nightingale Building - 67 University of Southampton Highfield Southampton SO17 1BJFOR OFFICE USE: Banner ID ................... POS ............ MUD .................. Continuing Professional DevelopmentApplication form for entry to individual modules of study Have you undertaken study at the University of Southampton 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 NameFirst NamesTitleDate of BirthMaiden/previous nameMaleFemaleHome addressTownPostcodeTelephone NumberHome:Mobile:E-mail addressPart B - 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 Current Job Title and Grade Name of Employing Trust/Organisation Your Work addressWardAddressPost CodeTelephone Number (including extension)Part C - English Language Proficiency Please complete this section fully and, if possible, enclose a copy of your English language certificate with the application form. Please note: as a condition of your offer for a place on a module, you may need to supply the original transcript. English language qualifications must date back no more than three years. a. Do you consider English to be your first language? Yes No If yes, please go to Part D of this form. If no, please go to next question b. Does your country appear on our list of countries exempt from Yes No English language tests? (visit soton.ac.uk/international/join_us/countriesexemptlangtest.html) If yes, please go to Part D of this form. If no, please go to next questionc. Have you taken an English language proficiency test in the last 3 years? Yes No If yes, please go to next question. If no, please go to question e. d. Please provide details of the test date and outcome. IELTS Scores: Overall Listening Reading Writing Speaking Test Report Form (TRF) number (if known)Date TOEFL Scores:TotalEssayDate Other English language qualification:TitleScoreDate e. Are you planning to take an English Language test? Yes No If yes, please provide details of the planned test and date If no, please note that you maybe required to take an English Language test as a condition of entry to a programme. Part D - Module Registration Details CODE MODULE TITLE START DATETICK IF MODULE IS PART OF PROGRAMME PATHWAY AUTHORISED CONTRACT SIGNATURE + FUNDING DETAILSRegistration 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 an NHS contract place you must complete the enclosed payment form and return it with this application. Authorisation of allocation of contracted place If more than one module is selected please indicate clearly above the funding arrangements for each module.Authorised Signature Name in Block Capitals Comments NHS Contracted Place: Yes Please tick which: Preferred Provider funding Flexible fundingHealth Education Wessex FundingOther Source of Funding(please specify) ___________________________We are required to ask the following questions for special requirements, University regulations, and statutory reporting purposes. Part E – 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 aboveAre you receiving Disabled Student Allowance from your funding body?YesNoAwaiting outcome of claimIf you have a criminal conviction which you are required to declare please tick this box (Please see the guidance notes for further information) 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 police 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 Sponsor/Seconding Trust. ? I agree to abide by the University’s rules and regulations if I am accepted onto a module. Signed (Applicant) Date Part G - Declaration by Seconding/Sponsoring Trust or Employer External applicants: to be completed by manager (if applicable) Secondment/Sponsorship Normally students will be accommodated to undertake any clinical practice component of a module/programme in their own practice setting. For those students who are seconded or sponsored, an honorary contract for the length of the module/programme will be provided by the Trust/ Employer accepting them for clinical placement. The student will be expected to abide by the policies and practices of the organisation accepting them for clinical placement(s). I confirm that this applying candidate will be fully or partly seconded under the above terms. Name of Trust/Employer Manager’s Signature Part H - to be completed by Manager Declaration by manager I confirm that:(Applicant’s 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).? Police screening 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 University of Southampton 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 D or the Module Payment Form. ? Required to take Assessment for Credit. Attendance is a Result of Appraisal Yes No Date: Manager’s 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 backgroundI 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 Study___________________________________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 RN7FeverRN9Part 2 - Midwives Field of practiceRegistration entry code MidwiferyRMPart 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- FHNRFHNRecorded qualifications PrescribingV100 Community Practitioner Nurse Prescriber V200Nurse Independent PrescriberV300Nurse Independent/Supplementary PrescriberSPANSpecialist Practitioner - Adult NursingSPMH Specialist Practitioner - Mental Health SPCNSpecialist Practitioner - Children’s 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 Children’s Nursing SPDNSpecialist Practitioner - District Nursing Guidance Notes Additional Needs We are committed to delivering services and support that will allow every student to fulfil his/her 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 University’s 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 H 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. English Language Proficiency If your first language is not English, and you do not already hold a degree from a UK University, you will be required to achieve a satisfactory result in an approved English Language test. This will ensure that you can enjoy the full benefits of your university studies.Nationals from certain countries are exempt from English language tests. For details see our International Students’ web pages at soton.ac.uk/international/join_us/entryreqs.html or contact the International Office at international@soton.ac.uk. The University accepts a range of qualifications. For a list of acceptable qualifications please consult the postgraduate and undergraduate prospectus. Our entry requirements for international students are also listed on the International Students’ web pages at soton.ac.uk/international. In general, only qualifications attained in the last three years will be accepted as evidence of current language proficiency. If you have already taken an English language test please give full details in the space provided. Please provide evidence of the qualification (ie, certificate) with your application. Any offer of admission will remain conditional until the original documents have been submitted (with the exception of IELTS courses). If you have recently taken an IELTS test, please supply the 18-digit Test Report Form (TRF) number for verification. Further information Ethnic Origin FormPlease complete the separate Ethnic Origin Form. This information is used to monitor the University’s 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 University’s 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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