Bsc (HONS) PRE REGISTRATION MIDWIFERY

Faculty of Health and Human Sciences School of Nursing and Midwifery

BSc (HONS) PRE REGISTRATION MIDWIFERY ELECTIVE RECORD

Please note: A separate form will be required if undertaking an elective in more than one Trust.

Name: Uni Number:

Name of Elective Mentor/Supervisor

Elective Details (Trust/Ward/Specialism)

Elective Trust Telephone Number From (date): To (date): Dates of elective

RECORD OF SIGNATURE AND INITIALS The signature and initials of the placement mentor/supervisor must appear on this form together with those of others with whom the student midwife has worked.

Name Signature Initials

Midwifery Elective Record Page 1 of 2 Mentor/Supervisors Report :

Name: Professional Role:

Signature: Date:

On completion of the elective placement this form should be discussed with your Personal Tutor after which it should be forwarded to the Programme Administration Team.

Midwifery Elective Record Page 2 of 2