How to Complete the Application Form

School of Health, Community & Education Studies

POST QUALIFYING/POST GRADUATE STUDIES CONTINUING PROFESSIONAL DEVELOPMENT (CPD) FRAMEWORK NB: This does not lead to Professional Registration

1 PERSONAL DETAILS

ALL PARTS IN THIS SECTION MUST BE COMPLETED THIS IS ESSENTIAL INFORMATION REQUIRED FOR ALL APPLICATIONS

1. TITLE ……………………………. 2. SURNAME ……………………………………………………………..

3. FORENAME(S) ……………………………………………………………………………………………………………………………..

4. FORMER NAME (as at age 16) …………………………………………………………………………………………………………..

5. GENDER: …………….. 6. DOB : _ _ / _ _ _ / _ _ (dd/mm/yy) 7. Relationship status: …………………………………

8. HOME ADDRESS …………………………………………………………………………………………………………………………..

…………………………………………………………………………………………………………………………………………………

POSTCODE …………………………………………. TEL. NO. (incl. STD Code) ……………………………………………………..

EMAIL ADDRESS …………………………………………………………………

9. PROFESSIONAL AREA

Nursing  Midwifery  Physiotherapy  Occupational Therapy  Social Work 

Medical Practitioner  Other please state ……………………………………………………………………………………..

10. PROFESSIONAL REGISTRATION

Name of Professional Body ………………………………………………………………………………………………………

Professional Registration Status ……………………………………………………………………………………………………..

Professional Body PIN ………………………………………………………………………………………..

11. ETHNIC ORIGIN NATIONALITY ……………………………………………………..

British – White  British – Black  Other European – White  Other European – Black  Asian – White  Asian – Black  American – White  American – Black  Australian – White  Australian – Black  African – White  African – Black  Prefer not to state 

12. LEARNING SUPPORT REQUIREMENTS

Do you consider yourself to be disabled? Yes  No 

Do you have any special support needs as a result of this? ………………………………………………………………………………………………………………………………………………………………… EMPLOYMENT DETAILS 2 This is essential to ensure relevant charges for your study are paid by the Strategic Health Authority, otherwise you will be charged individually for your study. For queries in relation to eligibility of funding, please refer to http://www.northumbria.ac.uk/static/5007/hces/eligibility.pdf

1. NAME & ADDRESS OF EMPLOYER (ie NHS Trust or equivalent)

…………………………………………………………………………………………………………………………….

POSTCODE: ...... ESR NUMBER: …………………………………………………….. (NB – Postcode of Trust is essential) (NB this is located on your payslip and is essential to your application)

2. NATURE OF ORGANISATION (e.g. Social Services, NHS Trust, Voluntary Organisation)

…………………………………………………………………………………………………………………………….

3. POST ………………………………………………… NUMBER OF HOURS WORKED ………………………

4. DEPARTMENT/WARD (if relevant) …………………………………………………………………………………..

5. SPECIALITY …………………………………………………………………………………………………………….

6. WORK BASE ……………………………………………………………………………………………………………

7. ADDRESS ……………………………………………………………………………………………………………….

8. TELEPHONE NO (incl. STD code) ……………………………EMAIL ADDRESS……………………………………………

9. IF SELF FUNDING OR OUT OF NHS CONTRACT OR SPONSORED ACTIVITY, INVOICE TO BE SENT TO:

……………………………………………………………………………………………………………………………………………….

AUTHORISATION 3 This is essential to ensure Line Managers support your study. Check with your Line Manager whether your organisation require a Training Coordinator’s signature.

BY LINE MANAGER: I agree to support the applicant during the undertaking of his/her course of study and facilitate the achievement of learning outcomes.

PRINT NAME: ……………………………………………….. SIGNATURE: ………………………………………………….

DATE: ……………………………………………………

BY TRAINING COORDINATOR:

PRINT NAME: …………………………………….………… SIGNATURE: ………………………………………………….

DATE: ………………………………………………….. 4 DETAILS OF ACADEMIC ACHIEVEMENT Please list in chronological order. Evidence of achievements is required. Failure to provide evidence will delay the process of your application

Awarding University Title of Activity Year of Completion CAT’s Credits

Admission tutor’s decision regarding accreditation:

NON STANDARD ENTRY 5 If you do not have the minimum entry requirement of 20 credits at Diploma level study (level 5) please select your preferred entry route to Degree level study (level 6).

Please see further information on entry requirements and application process on the Post Qualifying (CPD) website to inform your choice.

Module NG0105 Enquiry and Research for Practice  20 credits

Accreditation of prior experiential learning against the learning of the Module NG0105  20 credits 6 MASTERCLASS OPTIONS

Please include the name and date of the master class(es) you wish to attend. A menu will be available via the post qualifying website

Name______Date______

Do you wish to apply for accreditation of the learning arising from attendance at 5 master classes

No  Yes  20 credits

SINGLE MODULE REGISTRATION 7 Please include the name and code of the single module(s) you wish to attend. Please note that they will not lead to any specific award.

Name______Code______Name______Code______Name______Code______

PRACTICE EDUCATION & DEVELOPMENT 8 This module is required to teach and assess students in practice. It can be taken at level 5 (Diploma), Level 6 (Degree) or Level 7 (Masters) Please specify:

Facilitating Learning & Assessment in Practice Settings Code AC0507 20 credits level 5  Facilitating Learning & Assessment in Practice Settings Code AC6620 20 credits level 6  APEL Facilitating Learning & Assessment in Practice Settings Code AC0666 20 credits level 6  Facilitating Learning & Assessment in Practice Settings Code TE0757 20 credits level 7 

LONGER AWARDS IN HEALTH CARE 9 You may apply for a BSc (Hons) Degree 120 credits at Level 6 or Graduate Certificate 60 Credits at Level 6 or Postgraduate Certificate 60 credits at Level 7. (See CPD website for entry criteria.)

I wish to apply for:

BSc Hons. (Level 6) 120 credits  Graduate Certificate (Level 6) 60 credits 

Post-Graduate Certificate (Level 7)  60 credits NAMED AWARDS Provided you select the core modules and choose from the range of elective modules named for specific areas of practice, you may register for a named award. Please check on 10 the CPD website under named awards which modules are accepted for specific named pathways. www.northumbria.ac.uk/targetyourlearning

I wish to register for: Practice Development (generic mix of modules)  Cancer Care  Infection Control 

Palliative Care  Child & Adolescent Mental Health 

Sexual Health  Mental Health/ Learning Disability 

Critical Care  Paramedic Practice 

Post Graduate Certificate Practice Development (Level 7) 

SELECTION OF MODULES 11 Select THREE practice specific modules (ONE from each stream) and TWO core modules for a BSc (Hons) Select THREE practice specific modules (ONE from each stream) for a Graduate Certificate (Level 6) Select TWO practice specific modules (ONE from each stream) and ONE of the TWO core modules for a Post-Graduate Certificate (Level 7)

Practice Specific Modules Code Name Credits 20 ………………………………………………..…………………………………………………………. …………

20 ………………………………………………..…………………………………………………………. …………

Core Modules (For BSc – Tick if applicable.)

Learning for Practice Development (Portfolio One) 30 

Integrating Evidence for Practice Development (Portfolio Two) 30 

Core Modules (For Post-Graduate Certificate – Tick ONE if applicable)

Developing Skills for Service Improvement Planning (Level 7) 20 

Evidence for Practice Development (Level 7) 20  EMERGENCY CARE PRACTICE This specialist award has specific modules you must complete therefore you do not need select any options in section 10 of this form. Further information on the core modules for 12 this award is on the CPD website. Please select whether you wish to complete the Graduate Certificate or BSc award. www.northumbria.ac.uk/targetyourlearning

Emergency Care Practice BSc (Hons) 

Emergency Care Practice Graduate Certificate 

ASSESSMENT OF WORK BASED LEARNING (AWBL) LEVEL 6 ONLY 13 Up to 60 credits may be acquired through the AWBL process which gives academic credit for practice development work you may be involved in within your role. Further information is available via the CPD website www.northumbria.ac.uk/targetyourlearning

I wish to apply for AWBL 

Number of credits required 20  40  60 

14 APPLICANTS SIGNATURE

I the undersigned hereby agree that where requested, the University shall confirm periods of attendance and assessment performance with my employer or funding/ sponsoring body, as laid out in Northumbria University’s Handbook of Student Regulations.

I accept responsibility for confirming attendance for the education allocated and attending as agreed. Non confirmation of allocated places within the timeframe on the offer letter will result in withdrawal of the offer.

SIGNATURE: ………………………………..……………… DATE: ………………………………………

APPLICATION FORM TO BE RETURNED IN HARD COPY WITH RELEVANT SIGNATURES AND EVIDENCE OF PRIOR ACADEMIC STUDY TO:

Post Qualifying/Post Graduate Studies Northumbria University Room G209, Coach Lane Campus East Newcastle upon Tyne NE7 7XA Tel: (0191) 215 6222

ADMISSION TUTOR’S COMMENTS

Guidance Tutor………………………………………………….

SIGNATURE: …………………………………………………… DATE: ……………………………………………