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Learning Beyond Registration
Undergraduate
Specialist Practitioner Qualification
Application and Enrolment Form
This form can only be used to apply for the SPQ modules you wish to study within the academic year 2011 - 2012 within the East Midlands Strategic Health Authority (EMSHA) Learning Beyond Registration (LBR) contract 2011-2012. A full list of available modules and their dates and times can be found at: www.dmu.ac.uk/lbr Payment You must clearly identify on page 18 who will be paying for your chosen module(s)/programme. If the cost is to be covered by the EMSHA you will need to have this confirmed by obtaining authorisation from an EMSHA signatory. Only certain designated individuals have the authority to sanction funding. The full list of authorised signatories can be found at: http://www.dmu.ac.uk/faculties/hls/nursingmidwifery/lbr/trusteducleads.jsp Failure to do this or to identify another source of payment may result in your form being returned or with you being invoiced personally for the cost of the modules. Submitting the completed form All sections of the combined application and enrolment form must be completed. The form will be returned if any section is incomplete. This will delay the processing of the form and may affect the allocation of a place. All pages of the form must be returned in numerical order and be securely stapled. All applicants MUST include with this form photo copies of educational and professional qualification certificates (please see page 6). Please remember to make a note of the modules you wish to study before you send in your application form. New applicants only : Please also include two passport photographs with your name and date of birth written in capitals on the back. Secure these to your form. Closing date for applications: Semester 1 Friday 26th Aug 2011 Semester 2 Friday 6th Jan 2012 Semester X Friday 20th April 2012 Please return the completed form to: LBR Administrator Promotion and Recruitment Team De Montfort University Edith Murphy House, Room EM0. The Gateway Leicester LE1 9BH Tel: 0116 257 7700 If you have any questions please contact the LBR admissions team: [email protected] The LBR admissions team will write to confirm your offer of a place.
PLEASE COMPLETE ALL THE FIELDS
Personal Details
Profession (please tick one) Nurse Midwife Allied Health Professional NMC/HPC PIN Professional Number Title Mr Mrs Miss Ms Other (please specify) Surname Forename/s Previous Surname Male Female Date of Birth D D M M Y Y Y Y Home Address Postcode Home Tel Mobile No Work Tel Home email Work email Start Date: Month Year Y Y Y Y Full time Part Time Have you previously studied at DMU Post Reg Yes No Have you previously studied at DMU Pre reg Yes No If yes, what is your previous student no. P Unique Learner No. Office use only new student number allocated:
If you have changed your name please provide a copy of the relevant documents e.g.
marriage certificate or deed of name change etc
Emergency contact
Please enter the name and number of the person to contact in an emergency. The University will inform
your emergency contact if your well-being is threatened and you are unable to give instructions.
Name Contact Telephone Relationship to applicant
Type of Accommodation (please tick one)
Own home Privately Rented Parent/Guardian home Halls of Residence Other (please specify)
Council Tax Authority (please tick one)
Leicester Blaby Oadby & Wigston Charnwood Harborough Other please specify: Programme Code Programme Title
Occupation
If you are under 21, please enter the occupation of your highest paid parent or guardian in A, or if you are over 21 please enter your current or previous occupation in B A) Under 21 B) 21 or Over
Previous Educational Experience
Do any of your parents or guardians have any higher education (HE) qualifications i.e. degree, diploma, or certification of HE? (please tick one) Yes No Don’t Know Information refused Have you ever been on a Higher Education course in the UK for 6 months or more. E.g. HNC, BA, BSc? Yes No Where did you gain your professional registration qualification?
Relevant Professional experience
Please give details of your relevant professional experience (most recent first) over the last 5 years. Post Held Type of practice area eg surgery, medicine, community etc From (yyyy) To (yyyy) Where do you work now? Specific name of ward, unit department Full address of work place and contact telephone number and email
Level 8 Level 3 UK Doctorate degree (PhD) Qualification at Level 3 of EU Other EU Doctorate degree Qualification at Level 3 of non-EU Non-EU Doctorate degree Diploma at Level 3 Level 7 – previously described as level 5 Certificate at Level 3 UK Masters degree NVQ Level 3 Other EU Masters degree SVQ Level 3 Non-EU Masters degree GNVQ/GSVQ Level 3 Professional qualifications at Level 7 Foundation course at FE Level Integrated UG/PG taught Masters degree A-Level or AS Level (GCE and VCE) PG Diploma at Level 7 Advanced Higher (Scotland) (including CSYS) PG Certificate at Level 7 Higher (Scotland) PG Cert or Prof Graduate Diploma in Education BTEC National in early years Other Qualification at Level 7 BTEC Nationals Qualification at Level 7 Architects Registration Board (Pt 2) CACHE Level 3 Diploma in Child Care & Education Postgraduate credits AAT NVQ Level 3 in Accounting Level 6 – previously described as level 3 International Baccalaureate (IB) Diploma UK Bachelors degree with honours International Baccalaureate (IB) Certificate Ordinary (non-honours) first degree Irish Leaving Certificate (Higher) Other EU first degree Irish Leaving Certificate (Ordinary) Non-EU first degree OCR Nationals Professional qualifications at Level 6 Progression Diploma First degree leading to QTS Welsh Baccalaureate NVQ Level 6 Cambridge Pre-U Diploma SVQ Level 6 Professional Qualification at Level 3 GNVQ/GSVQ Level 6 Other Qualification at Level 3 Professional Graduate Certificate in Education Diploma in Foundation Studies (Art & or Design and Media) Other Qualification at Level 6 Advanced Modern Apprenticeships Undergraduate credits at level 6 HE Access course, QAA recognised Level 5 – previously described as level 2 HE Access course, not QAA recognised Qualification at Level 5 of EU Mixed Level 3 quals of which some are subject to Tariff Qualification at Level 5 of non-EU Mixed Level 3 quals of which none are subject to Tariff Professional qualifications at Level 5 Diploma at Level Q Diploma of Higher Education RGN / RM Certificate at Level Q Foundation degree Level 2 NMAH 2000 (from DMU LBR contract) RTS NVQ Level 2 HND (including BTEC & SQA equivalents) SVQ Level 2 NVQ Level 5 GCSE/O Level qualification SVQ Level 5 Intermediate (Scot) GNVQ/GSVQ Level 5 Standard Grades (Scot) Foundation course at HE level Professional Qualification at Level 2 Cert or Dip of education (i.e. initial teacher training qual) Other Qualification at Level 2 Level 4 Level 1 Qualification at Level 4 of EU NVQ Level 1 Qualification at Level 4 of non-EU SVQ Level 1 Professional qualifications at Level 4 SRN Professional Qualification at Level 1 Certificate of Higher Education Other Qualification at Level 1 HNC (incl. BTEC & SQA equivalents) Other Qualification at Level 4
Previous Educational Institution including DMU if applicable
Name of Institution Address Postcode Date left D D M M Y Y Y Y
Workplace
Please identify your Trust or employer, e.g. University Hospitals of Leicester (please tick one)
Acute Trusts
Chesterfield Royal Hospital NHS Foundation Trust RFS Nottingham University Hospitals Trust RX Derby Hospitals NHS Foundation Trust RTG Sherwood Forest Hospitals NHA Trust RK Doncaster & Bassetlaw Hospitals NHS Foundation Trust RP United Lincolnshire Hospitals NHS Trust RWD Kettering General Hospital NHS Trust RNQ University Hospitals of Leicester NHS Trust RWE Northampton General Hospital NHS Trust RNS
Primary Care Trusts
Bassetlaw PCT 5ET Lincolnshire PCT 5N Derby City PCT 5N7 Northampton PCT 5PD Derbyshire County PCT 5N6 Nottinghamshire County Teaching PCT 5N Leicester City PCT 5EJ Nottingham City PCT 5EM Leicestershire County and Rutland PCT 5PA
Mental Health and Learning Disability Trusts
Derbyshire Mental Health Services NHS Trust RXM Northamptonshire Healthcare NHS Trust RP Leicestershire Partnership NHS Trust RT5 Northamptonshire Healthcare NHS Trust RP Lincolnshire Partnership NHS Trust RP
Other
East Midlands Ambulance Service NHS Trust RV6 Other NHS – please specify Not an NHS Employee 001
Programme Details Please find below a table which shows the requirements for each programme available. Find your intended award title on the left and read across to identify specific requirements for that award. Please ensure you meet these. Please note that if you already possess a nursing degree associated with your initial professional registration you CANNOT apply to undertake a further undergraduate degree. On accumulation of 120 degree level credits, such students will be awarded a Graduate Diploma in their chosen programme. On accumulation of 60 credits, such candidates may be able to exit their programme with a Graduate Certificate. Requirements for Programme Programme Title Code 120 credits at level 4 and at least 2 years experience 120 credits at level 4 & 5 with at least 1 year experience or 30 credits at level 5 and 3 years experience Mentor Sign off mentor as per NMC (2008) stand- ards Sign off practice teacher as per NMC (2008) stand- ards BSc (Hons) Specialist Practitioner with NMC SPQ in either Adult, Child, Learning Disabilities, Community Learning Disabilities, Mental Health, Community Mental Health or General Practice District Nursing B Graduate Diploma Specialist Practitioner with NMC SPQ in either Adult, Child, Learning Disabilities, Community Learning Dis- abilities, Mental Health, Community Mental Health, General Practice District Nursing B If you require further information please go to the web site www.dmu.ac.uk/lbr or contact the following : Programme code Programme title Contact B70050 BSc (Hons) Specialist Practitioner Qualifications Deborah Dowsett [email protected] LBR Adminisions Tutor Theresa Jackson [email protected]
Data Protection Act Statement & Student Declaration
I understand that by signing this form I am agreeing to be liable for all tuition fees incurred over the duration of my programme of study, in whole or in part, and that if I fail to pay my tuition fees in a timely manner that DMU reserves the right to terminate my studies. I understand that De Montfort University reserves the right to prosecute me in order to recover any debt. In accordance with the Data Protection Act 1998 the University requires your consent to collect and use personal information. I agree to De Montfort University processing personal data contained in this form or other data which the University may obtain from time to time from me or other people whilst I am a student as documented in the section on Protecting Data included in my Student Handbook. I agree to the processing including sharing with partner organisations of such data for any legitimate purpose connected with my studies, including placements or my health and safety. The Managing Information Across Partners (MIAP) programme offers a service to allocate Unique Learner Numbers (ULNs) to students. The ULN enables individuals to access a Learner Record which will offer learners the facility to access their participation and achievement data via a website and to share this with other organisations and individuals where permissions is granted. The MIAP service will allow those organisations listed on section 537A of the Education Act to use the ULN as a key to sharing participation and achievement data in a consistent and approved manner, promoting good information management practice. All organisations that will have access to the information you provide are registered under the Data Protection Act 1998. At no time will your personal information be passed to organisations for marketing or sales purposes. Individuals can opt out of sharing participation and achievement data with those organisations listed in section 537A of the Education Act by ticking this box. More information about opting out or data sharing can be found at www.miap.gov.uk (FAQs) or by telephoning the MIAP Learner helpdesk on 08702 401 453. I declare that the information contained in this form is correct and understand if I have knowingly given false information I may be excluded from De Montfort University. I agree to abide by the University’s regulations. I understand that the programme for which I am enrolling is subject to availability. Signed by Applicant
Date D D M M Y Y Y Y
Criminal Convictions (To be completed by all applicants)
You are applying for the SPQ professional programme, which on successful completion will be recorded with the NMC. You must declare ANY spent or unspent criminal convictions, including cautions, warnings and reprimands. You must also declare any offences for which you have been charged including speeding offences. If following your application any of the above applies you must inform the Faculty admission office immediately. Telephone 0116 257 7700 Email [email protected] Please note that having a criminal conviction will not necessarily prevent you from studying at De Montfort University. For further information please view our Admissions policy http://www.dmu.ac.uk/aboutdmu/policy/index.jsp Access criteria includes the submission of a Full Enhanced Disclosure from the Criminal Records Bureau. This must have an effective currency of 3 years from the start date of your programme. Please attach a copy of this to your LBR application/enrolment form. Place the copy of the full enhanced CRB into a sealed enve- lope marked confidential and send with this form. Your offer is conditional upon receipt of a satisfactory recent full enhanced CRB as per NMC standards. It is your responsibility to ensure that this is available prior to the commencement of your studies on this programme and must be produced at interview. Applicants please sign and date to verify the above and complete the self declaration over leaf.
NOTES
If you are not sure whether to tell us about a previous criminal convictions, including cautions, warnings and repri- mands you can obtain more advice from your local Citizens Advice Bureau or Probation Service or the national As- sociation for the Care and Resettlement of Offenders (NACRO). You can also contact a solicitor, but you may have to pay for these services. If you are serving a prison sentence, you must select yes. You must also give the prison address as your postal ad- dress and a Senior Prison Officer must support your application. As the line manager of the applicant below I am signing to confirm that they have had a full enhanced CRB within the last 3 years. Applicants name in capital letters: Applicant to sign and date:
- Have you ever been CONVICTED, BOUND OVER, received a FIXED PENALITY NOTICE OR RESTORATIVE JUSTICE for any criminal offence in the United Kingdom or in any other country? Yes No
- Have you ever been CAUTIONED, STREET CAUTIONED, REPRIMANDED or received a FINAL WARNING by the police for any offence in the United Kingdom or any other country? Yes No
- Have you been charged with any offence in the United Kingdom or in any other country that has not yet come to court? Yes No If YES (for any of the above) please specify the corresponding question your answer relates to; a. Please give date(s) b. What was the charge(s)? c. What were the circumstances regarding the charge(s)? d. What was the outcome?
- Are you currently under investigation for any alleged offence in the United Kingdom or in any other country? Yes No If YES (for the above); a. Please give date(s) b. What are the circumstances regarding the charge(s)/investigation(s)? Who are you being investigated by? c. What was the outcome? The University has a duty to assess the fitness to practise of applicants to specific courses, for example Social Work, Pharmacy and Nursing. For this reason, we need to obtain information relevant to an individual’s fitness to practise as a professional working with vulnerable members of the community. It is for this reason that we need to ask the following questions about previous conduct that might lead to or has led to sanction by a professional body, education institution and/or employer.
- Are you currently or have you ever been the subject of any investigation or fitness to practise proceedings by a professional/statutory body, previous educational establishment or current or past employer in the United Kingdom or any other country? Yes No Please provide details: reason for the investigation, the date of the investigation and the name and address of the relevant professional/statutory body;
Information Reviewed by:
Faculty Admissions Head of School Date Decision and/or referral to Admissions Tutor/CRB Lead Date Decision and/or referral to FTP Tutor Date Decision and/or referral to Panel Lead/FTP Lead Date Decision and/or referral to Professional/Statutory Body Representative Date Decision and/or referral to
Criminal Convictions (To be completed by the applicants manager)
The applicant is applying for the SPQ professional programme, which on successful completion will be recorded with the NMC. They must declare ANY spent or unspent criminal convictions, including cautions, warnings and reprimands. They must also declare any offences for which they have been charged including speeding offences. If following their application any of the above applies they must inform the Faculty admissions office immediately. Telephone 0116 257 7700 Email [email protected] Please note that having a criminal conviction will not necessarily prevent them from studying at De Montfort University. For further information please view our Admissions policy http://www.dmu.ac.uk/aboutdmu/policy/index.jsp Access criteria includes the submission of a full Enhanced Disclosure from the Criminal Records Bureau. This must have an effective currency of 3 years from the start date of their programme. They must attach a copy of this to their LBR application/enrolment form. They must place the copy of the full enhanced CRB into a sealed envelope marked confidential and send with this form. Their offer is conditional upon receipt of a satisfactory recent full enhanced CRB as per NMC standards. It is their responsibility to ensure that this is available prior to the commencement of their studies on this programme and must be produced at interview. Managers please sign and date to verify the applicant below and that they have complete the self declaration over leaf.
NOTES
If an applicant is not sure whether to tell us about a previous criminal convictions, including cautions, warnings and reprimands they can obtain more advice from their local Citizens Advice Bureau or Probation Service or the national Association for the Care and Resettlement of Offenders (NACRO). They can also contact a solicitor, but they may have to pay for these services. If the applicant is serving a prison sentence, they must select yes. They must also give the prison address as their postal address and a Senior Prison Officer must support their application. As the line manager of the applicant below I am signing to confirm that they have had a full enhanced CRB within the last 3 years. Applicants name in capital letters: Full enhanced serial number Issue Date Manager to sign and date: OFFICE USE The above applicants full enhanced CRB form which is within 3 years of starting their programme has been viewed and verified by: Print name Signiture Position Date The information has also been entered in the DMU database.
Applicants who are self-funding Please confirm that you are the person to be invoiced for the cost of the modules by completing the following section. Name Address Position Signature Trust/Practice area Tel No Date
For UHL staff only
Deputy Director of nursing Print Name: Signiture Date
ALL APPLICANT CHECKLIST
Before submitting this form, please ensure all sections have been completed: Have you answered ALL the questions? The LBR declaration has been signed and completed indicationg yes or no and N/A where applicable. Both criminal conviction pages have been completed. You are sending your current copy of your enhanced CRB form which is within 3 years of the start of your programme. Have you clearly identified the programme and module you wish to study on page 9? Have you included copies of your educational and professional certificates as per requirements on page 6? Have you signed to confirm that you meet the entry requirements for your chosen Programme on page 9? Have you clearly identified the Modules you wish to study on page 9? Have you taken a copy of the completed form for your own reference? Copies of educational/professional certifcates as per page 6
- Current NMC/HPC pin card
- Educational/Professional qualification certificates
- Evidence of HE diploma levels study (Not required for the return to study, module) If your name has changed please provide a copy of the relevant documents eg marriage certificate or Deed of name change etc. As per page 2 Have you included 2 passport sized photographs and written your name in capitals on the back with your date of birth? Only required if you are a new applicant or wish to submit a more up to date photograph for your ID card as per page 1.
