DESIGNATED MEDICAL PRACTITIONER (DMP) FORM

As part of the University’s Quality Assurance processes we are required to formally appoint all Designated Medical Practitioners as visiting practitioners of the University of Bath. In order to help us to do this, can you please complete this short questionnaire and short CV proforma outlining your relevant clinical and teaching experience. You may submit your own CV if this is up to date and covers this information.

Once we are in receipt of this information, we will be able to provide you with an email account at the University, as well as access to the internet-based Virtual Learning Environment, which we will be using as the support mechanism for this programme.

Please note that the University will provide full support for you in your role as a Designated Medical Practitioner and has appointed a Mentor to act as an adviser for DMPs during the period of study of this programme.

Please complete and return the form to the applicant for uploading to their online application:

Name of DMP

Current Post:

Registration Number:

Qualifications (attach CV or complete the Bath short CV template)

Contact Details:

Address:

Telephone Number:

Email:

Name of Student

Could you please supply the following information? This will assist us in making sure the Department of Health criteria for the supervision in practice of supplementary pharmacist prescribers are being met.

Please tick the box with the relevant response.

Department of Health (Nov 2001) Criteria

Are you a registered medical practitioner who:

(i)has had at least 3 years medical, treatment and prescribing responsibility for a group of patient/clients in the relevant field of practice?

YesNo

and are you:

(ii)(a) within a GP practice and either vocationally trained or in possession of a certificate of equivalent experience from the Joint or Post-Graduate Training in General Practice ?

Yes No

OR (b) a specialist registrar, clinical assistant or a consultant within a NHS Trust or other NHS employer?

Yes No

and have you:

(iii)the support of the employing organisation or GP practice to act as the designated medical practitioner who will provide supervision, support and opportunities to develop competence in prescribing practice?

Yes No

and have you:

(iv)some experience or training in teaching and/or supervision in practice ?

Yes No

If you are not an Approved Training Practice/Institution, then please outline your experience of teaching, supervision and assessment of students.

Statement of Support

Please provide a statement about the professional competence of the above-named student, along with an assessment of their ability to undertake the programme as outlined above.

I confirm that I have agreed to supervise the student in their prescribing role for a period of learning in practice of at least 12 x 7.5hour days.

SignedDate

University of Bath

Department of Pharmacy and Pharmacology 2018