<p> Faculty of Health and Human Sciences School of Nursing and Midwifery</p><p>BSc (HONS) PRE REGISTRATION MIDWIFERY ELECTIVE RECORD</p><p>Please note: A separate form will be required if undertaking an elective in more than one Trust.</p><p>Name: Uni Number:</p><p>Name of Elective Mentor/Supervisor</p><p>Elective Details (Trust/Ward/Specialism)</p><p>Elective Trust Telephone Number From (date): To (date): Dates of elective</p><p>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.</p><p>Name Signature Initials</p><p>Midwifery Elective Record Page 1 of 2 Mentor/Supervisors Report :</p><p>Name: Professional Role:</p><p>Signature: Date:</p><p>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.</p><p>Midwifery Elective Record Page 2 of 2</p>