<p>Major change (approval) submission form for stand alone Prescription only medicines – sale / supply programmes</p><p>To help you complete this form please refer to the accompanying guidance</p><p>There are three sections of this form which need to be completed:  Section 1 About the stand alone Prescription only medicines – sale / supply programme  Section 2 Further information about the stand alone Prescription only medicines – sale / supply programme  Section 3 Confirmation</p><p>Section 1 – About the stand alone Prescription only medicines – sale / supply programme Name of education provider Name of awarding/validating body (if different from education provider) Programme title (stand alone Prescription only medicines – sale / supply programme title) Name of Department, School or Faculty (to which the programme belongs) Programme leader </p><p>Mode of delivery Full time Part time Other (please provide details) </p><p>Contact details for person responsible for submitting the form to the HCPC Name Job title Telephone number Email address Check list of documents required for stand alone programme:</p><p> Module descriptor  Completed HCPC mapping document for SETs 2 and 3.3  Information for applicants  Admission / entry criteria  Monitoring and evaluation processes </p><p>If difference in academic level of stand alone programme to approved podiatry programme, further documents required:</p><p> Assessment and learning outcomes for stand alone programme </p><p>Section 2 – Further information about the stand alone Prescription only medicines – sale / supply programme Are there any differences between the potential stand alone programme and the module within the HCPC approved chiropody / podiatry programme (academic level of programme for example)? If yes, please provide information on the differences</p><p>Have there been any recent changes in the curriculum content for this particular module? If yes, please provide information regarding the change</p><p>Are the facilities and resources provided, both on and off site, able to adequately support the learning and teaching activities of this programme?</p><p>Section 3 – Confirmation</p><p>I confirm that all information relating to the proposed stand alone Prescription only medicines – sale / supply programme which has been submitted is correct.</p><p>Name </p><p>Job title Date </p><p>Please return this form to: Education Department, The Health and Care Professions Council, Park House, 184 Kennington Park Road, London, SE11 4BU or [email protected]</p>