L Pre Registration Training



Non-Medical Prescribing (NMP) Programme February 2019APPLICATION FORM - Pharmacist Type in BLACK Enter a cross ‘x’ in boxes where indicated. INCOMPLETE FORMS WILL NOT BE PROCESSED856615698500Pharmacist (Currently registered and practising) Is this your first application to any 35655257620002841625889000Non-Medical Prescribing Programme? Yes NoIf no, provide details in Section 5LOCALITY Section 1YOUR PERSONAL DETAILSSurname/Family Name/Last NameTitle (Mr/Mrs/Miss/Ms/Mx/Dr etc.)First Name(s) in full Date of Birth(dd/mm/yyyy)GenderFemale/Male/OtherPrevious First Name(s) in fullPrevious Surname(s)/Family Name(s)/Last Name(s)Home AddressPost CodeAddress for programme materials (if different from home address)Post CodeDaytime telephone numberEvening telephone numberMobile numberOU Personal Identifier (if applicable)Email address Professional Registration Detail (GPhC Registration)-444516573500Country of Birth NationalityResident Status23323551601820036578916099400If not a British or EEA national, do you have resident status within the UK?YesNoSection 2 Programme PrerequisitesEnter ‘x’ in the appropriate box only if the requirement is fully met. To be completed by the applicant.I confirm that I am currently registered with the GPhC:44894510922000YesI confirm that I have at least two years appropriate patient-orientated experience in a UK hospital, community or primary care setting following my preregistration year:***Or44894510922000YesI have identified an area for clinical practice in which to develop my prescribing skills and have up to date clinical, pharmacological and pharmaceutical knowledge relevant to this area of prescribing practice: ***44894510922000YesI have a DMP and organisation who has agreed to provide me with supervision, support and shadowing opportunities: +++4514858382000Yes I take responsibility for my personal development, have a completed CPD record and reflect upon my own performance in practice: ***4591059906000Yes I have a valid current DBS certificate: Your employer can confirm by email the DBS number and date checked.44894510922000YesI confirm I am not undertaking any other programme of study and I am prepared for around 600 hours of total study:4591058572500Yes I have completed the sample numeracy assessment (online):Available at (TBA)44894510922000YesWho will be funding your place on the NMP Qualification?Please delete as appropriate. Employer / Self*** further details are required in Section 5+++ further details are required in Sections 3 & 4Please note if clarification is required for this or any part of this form please contact the Qualification Lead (currently Richard Lowe) on 01908 652325 or by email to Richard.Lowe@open.ac.ukSection 3 Organisational SupportEnter ‘x’ in only one of the option boxesThis section should be completed by the Prescribing Lead in the supporting organisation (or equivalent (please state). If this is not the applicant’s employing organisation reciprocal governance contracts (e.g. through arrangement of an honorary contract) must be in place prior enrolment.I agree that the following aspects of the NMP programme have been discussed and can confirm the following:Support for the pharmacist in the group of patients specifiedExperienced clinicians with the relevant skills are available to provide ingoing practice-based support for training in prescribing Release is available for the full 26 days of training. This is to include the specified dates for the four face to face days on campus and a specified half-day exam in one of the OU exam centresThe applicant has at least two years appropriate patient experience * Support for future prescribing practice is available within the organisation once training has been completed *44894510922000YesNameDatePositionOrganisation* If you are in private practice, here and elsewhere, further examples, for example, by means of separate statements from a previous employer or equivalent may be required. In these instances, or if further clarification is required, please contact the Qualification Lead (currently Richard Lowe) on 01908 652325 or by email to Richard.Lowe@open.ac.uk Section 4Designated Medical Prescriber (DMP) SupportThis section must be completed by your agreed DMP.As a DMP, before you complete your section of the form, please read the statements below as your signature confirms your support for and commitment to this applicant. I confirm that the applicant is a suitable applicant and I confirm my support in his/her application to undertake the Non-Medical Prescribing Programme with the Open University. I am confident that I have sufficient information to fully understand the requirements for supporting a student on the OU non-medical prescribing programme. I have been offered an opportunity to discuss the programme with a representative of the Open University.I confirm that I will commit to…providing access to learning opportunities which enable achievement of non-medical prescribing competencies and compliance with GPhC requirementsproviding mentors and supervisors who meet satisfactory standards for mentorship, mentoring and supervision and other practice supervisors as required – Please note it is not necessary for students to spend all of the period of learning in practice with their designated medical practitioner (DMP), as other clinicians may be better placed to provide some of the learning opportunities. However, the DMP remains responsible for assessing whether all of the learning outcomes have been met.providing 90 practice-based hours to enable fulfilment of training requirements and NMP curricular hours’ requirementsassessing in the student’s competencies in practice according to the guidelines provided by the Open University – this will include the completion of a log of learning in practice, a correctly referenced competency framework and a practice-based assessment (PBA)Enter ‘x’ in the appropriate box only if the requirement is fully met. To be completed by the DMP.I confirm that the following demonstrates that the Department of Health criteria for the supervision in practice of students on a non-medical prescribing programme is met:I am a medical Practitioner who has had at least 3 years medical treatment and prescribing responsibilities for a group of clients/patients in the relevant field of practice.448310-3111500Yes I am a medical practitioner within a GP practice and I am either vocationally trained or in possession of a certificate of equivalent experience from the Joint Post-Graduate Training in General PracticeORI am a specialist registrar, clinical assistant or a consultant within an NHS Trust or other NHS employer.463550-7175500Yes I have the support of the employing organisation or practice which will provide supervision, support and opportunities to develop the student’s competence in prescribing practice.470535-508000Yes I have some experience or training in teaching and/or supervision in practice.501650-3238500Yes I agree to my details including any comments/marks/remarks are made available to the Open University and its educational partner ICST.448310-3111500Yes Section 4Designated Medical Prescriber (DMP) Support (continued)Designated Medical Practitioner DeclarationPrinted Name:Signature:Date:GMC Number:Organisation and Role/Position:Email Address:Telephone Number:Please note that DMP support is available in the form of a DMP handbook, an online video presentation and by email at any time to the Qualification Lead (currently Richard Lowe) on 01908 652325 or by email to Richard.Lowe@open.ac.ukSection 5Applicant Personal StatementYou must complete a personal statement to support your application. This statement should be original work, written by you and must include:A short summary of the service you are intending to provideThe identified area of clinical practiceThe service to be providedThe budgetary control and flow of patients (organisational need and management) A 500-word description of how you have kept your CPD relevant and up to date and how you are prepared for the Non-Medical Prescribing Qualification. Academic referencing is not required but this item should be written in prose and demonstrate a good use of English.Personal Statement (500 words - please expand box as required)Section 6APPLICANT DECLARATIONApplicant’s Name (please print): …………………………………………….Please ensure you have completed each of the sections listed below:Section 1 – Personal detailsSection 2 – Programme PrerequisitesSection 3 – Organisational SupportSection 4 – DMP AgreementSection 5 – Personal StatementSection 6 – This DeclarationI confirm that the information I have given on this application form and in all other application documents is a true, complete and accurate record, and that no information has been omitted.I am aware that information about me obtained as part of the application process will be shared with my employer, DMP, the OU and The Institute of Clinical and Science Technology ICST. ICST is a partner organisation of the OU and provide the learning materials and the VLE (Virtual Learning Environment) which co-hosts the NMP programme.I understand that The Open University reviews the NMP programme recruitment and selection processes on a regular basis and may contact me to ask me to participate in this review, whether or not I am successful in gaining a place on the programme.Applicant’s Signature: ……………………………………………………….Date: ………………….Please ensure this form is delivered to:Recruitment and Selection TeamDepartment of NursingThe Open UniversityWalton HallMilton KeynesMK7 6AA ................
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