Student Placement Enrolment Form

Student placement enrolment form

This form is to be used to arrange the enrolment of students with placements at the IoP.

The form should be completed by the student and the supervisor, and be submitted at least one month before enrolment is due to take place, to: Robina Cloralio Education Support Team, IoP PO Box 0090 [email protected]

In order to qualify for this scheme, the student should be: a) Studying as an undergraduate at another UK Higher Education institution b) Undertaking the placement as an accredited part of their studies

Students not meeting this definition will be taken through the Visiting Appointment process by IoP HR. Section 1: to be completed by the student

A Personal Details

* Surname/Family Name

* First Names

Name in which you are registered with a professional body (if applicable)

Title * Date of birth

Address

* Postcode/ Zip code * Country

Home Telephone Mobile Telephone

Email Address

B Fee and visa status Country of birth

Country of permanent residence

Nationality

Are you currently studying on a Yes No Tier 4 student visa?  

C Education & Professional Qualifications

Include in this section all the relevant qualifications. Please also indicate subjects currently being studied.

Subject/Qualification Place of Study Grade/result Year (start/end)

D Details of Current Programme of Study

Please confirm the following information

Name of current UK institution of study

Will this placement form an accredited part of your degree  Yes No programme?

Name and contact details of placement liaison officer in your institution of study

Address and postcode

Telephone

Email Address

E Duration

Proposed starting date Proposed end date

Duration of placement

F – Emergency contact details * Surname/Family Name

* First Names

Address

* Postcode/ Zip code * Country

* Home Telephone * Mobile Telephone

Email Address

Relationship of emergency contact to you – e.g. mother, partner etc.

Student Agreement I have read and agree to the terms of the Student Placement (see appendix 2), and have completed the information on disability (appendix 3) and submitted this separately

NAME ……………………………………………………………………………………………………..

SIGNATURE ………………………………………… DATE ………………………………… Section 2: to be completed by the supervisor

A Supervisor Information

Name and contact details of supervisor

Address and postcode

Telephone

Email Address

B Placement details

Proposed starting date

Duration of placement

On the first day the candidate should Location report to:

Weekly Stipend amount (if applicable): Will travel expenses be paid?  Yes No

Address where the student will be based:

Room Number Floor

Building Campus

Telephone

Will the student need to gain DBS and/or Occuapational Health clearance in order to perform their duties? Please click on the link below for information relating to clearance requirements https://internal.kcl.ac.uk/iop/stu/pgr/assets/clearanceforpgr.docx

Occupational Health clearance DBS clearance required Yes No Yes No   required  

Will the student require access to Yes No Name of Trust (if applicable) SLaM or any other NHS Trust?   This Student Placement is for the purposes of contributing to the student’s academic attainment and the department would not normally offer this position to any person

Department agreement

I have completed this form and am fully aware of the basis on which I am agreeing to supervisor this student. I have informed the student of the arrangements for payment of stipend/expenses.

Supervisor’s name: …………………………………. ……Signature ………………… Date …………………….

Head of Department’s name ……………………….. ….Signature …………………… Date ………………….

Business Manager’ name ……………………………….. Signature ………………….. Date …………………….

Please submit to Robina Cloralio in EST once completed and signed.

For completion by Education Support Team

Date of EST appointment (first day if Time of appointment possible)

Student provided with DBS & OH info?  Yes Not required Honorary Contract necessary?  Yes No

Student should bring their passport and any Visa documentation when enrolling

………………………………………………………………………………………………………………… Notes …………………………………………………………………………………………………………………

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

Please return to departmental Business Manager once approved and appointment arranged. Appendix 1: Payment authorisation for IoP Student Placements

INSTRUCTIONS FOR COMPLETION

If only one payment is required, please use the form 'Expenses Claim for KCL Staff, Students and Non-Staff'. Please complete all details in full.

If amounts are subsequently required to be increased, please submit a further spreadsheet for the additional amount only, not the revised figure as duplicate payments could result.

Please note: Payments may be set up for a maximum period of 36 calendar months in advance.If payment is required beyond that, a further request is necessary at that time.

The named supervisor is directly responsible for ensuring all payments made are within the terms and conditions of the sponsor and the budget provided.

Monthly Student Placement Funding Request

Supervisor Details

School …………………………………………………. Division/Dept ……………………………………………….

Full Name ……………………………………………………………………………………………………………………

Email Address………………………………………………………………………………………………………………

Authorised Signatory

Full Name………………………………………………. Signature………………………………………………………

Placement Student

Student Name…………………………………………………………………………………………………………..

Parent University……………………………………………………………………………………………………..

Name of Bank (UK Bank only)……………………………………………………………………………………..

Sort Code …………………………… Account Number…………………………………......

Payment Details

1st Payment Last Payment Total of No. of Account code Due Date ** Date Yearly Equal [XXXXXX-XXX] (ie 01/10/****) (ie 01/09/****) Amount Instalments NB Not a salary £ Monthly code

YEAR 1

YEAR 2

YEAR 3

END OF PERMITTED REQUEST

**(ie if the student stipend runs from 1st October but the student arrives after this date, the due date must still be entered as the 1st of October to ensure arrears are calculated accordingly)

Please return this form to Bought Ledger, James Clerk Maxwell Building, King’s College London Appendix 2: Student responsibilities during the placement

Behaviour

You will be expected to be courteous and respectful to other staff, students and clients during your placement.

Transport and Lunch

You will be responsible for making arrangements for transport and lunch.

Health and Safety:

You must:-

 take reasonable care to avoid injury to yourself or to others  report any accident or injury immediately and record the details according to KCL Health & Safety procedures.

You must not:-

 interfere with, or misuse any clothing or equipment provided to protect your Health and Safety.

Confidentiality:

You must not, at any time whether during or after the placement, disclose to a third party, any confidential information you obtain during your placement.

IT Access: (applicable to students given access to Information Systems)

You might be granted IS access during your placement. Whilst using KCL IT systems, you must comply with the KCL Data Protection and Confidentiality Policy. Appendix 3: Disability and ethnicity information - to be completed by the student

Please note that information collected within this part of the form will NOT be submitted for academic assessment

Disability Discrimination Act 1995

The Disability Discrimination Act protects disabled people. This includes people with long-term health conditions. If you tell us that you have a disability we can make reasonable adjustments to your work arrangements and at interview.

Name Date of birth

 Yes  I do not wish to disclose this information * Do you consider yourself to have a disability? No

If you have a disability do you require any specific arrangements to enable you to attend for interview? Yes  No N/applicable

If yes, please supply details below:

Please state the type of impairment which applies to you. People may experience more than one type of impairment, in which case you may indicate more than one. If none of the categories apply, please mark ‘other’.

 Physical Impairment  Learning Disability/Difficulty

 Sensory Impairment  Long-standing illness

 Mental Health Condition  Other

Ethnic Origin

Equality monitoring is important in helping the College to ensure our Equality and Diversity Objectives are relevant and effective, which is why we need to collect the following information from all potential students. Any data collected will be stored securely and used anonymously for equality monitoring purposes only. The contents of this section will be treated in strict confidence.

Please select the option which best describes your ethnicity

 Asian - Bangladeshi  Asian - Other  Black - Caribbean  Other  White and Asian

 Asian - Chinese  Asian - Pakistani  Black - Other  Other Mixed  White Black African

 Asian – Indian  Black - African  Not Given  White  White Black Caribbean

Please detach this form and send it separately to:

Robina Cloralio Education Support Team, Institute of Psychiatry King’s College London De Crespigny Park London SE5 8AF