Important this form will not be accepted by the Universityunless authorised by Education Co-ordinator/Manager

NHS Healthcare Organisation Authorisation ……………......

CONFIRMATION OF SCREENING YES/NO

Nomination for MENTORSHIP MODULE
2014/15 ACADEMIC YEAR
Please read through the form before proceeding then complete ALL relevantsections, incomplete forms will be returned which may jeopardise your place on the course
University Registration Number: (if known) …………………………………………….
Module Title: MENTORSHIP (APEL)
I have nominated ………………….………………………...... …… (Name in Block Capitals)
for a place on the following module(s) starting on ....……...... /..……...... /.…….....…
Module Code: MENT602  MENT 603 (distance Learning) 
MENT702  MENT 703 (distance Learning 
Please tick as appropriate
I verify that:
  1. I am the nominees line manager
  2. They have supported at least 2 individuals in a learning capacity over the last 2 years, meeting the HcPC Education standards or NMC Standards to Support learning and Assessing in Practice (NMC, 2008) 
or
  1. They have presented certificated evidence of undertaking a course commensurate with the Faculty of Health and Health Sciences APELTariff
Line Manger signature………………………………………………..
**Please note individuals must have a degree to enrol on the masters modules MENT702 or MENT 703
Module Title: MENTORSHIP (5 day course)
I have nominated ………………….………………………...... …… (Name in Block Capitals)
for a place on the following module
Module Code: MENT601  MENT701 please tick as appropriate
I confirm that they:
  1. Will be supporting a leaner during the course
  2. Have access to a personal Mentor (for Allied Health Professions (AHPs))
Sign Off Mentor (For Nurses and Midwives) for the duration of the course
Authorised ……………………………………………………..
…………………………………………………………………………………………
starting on ....……...... /..……...... /.…….....…
**Please note individuals must have a degree to enrol on the masters module
THE FOLLOWING SECTIONS MUST BE COMPLETED BY THE
MODULE APPLICANT
YOUR NAME DATE OF BIRTH AND PIN NUMBER SHOULD BE EXACTLY AS IT IS PRESENTED ON THE NURSING AND MIDWIFERY COUNCIL/ HEALTH AND CARE PROFESSIONS COUNCIL WEBSITE.
PERSONAL DETAILS
Surname...... …………
Maiden Name...... …………
Title(Mr,Mrs,Miss,Ms)...... …......
Nationality ………………………………………… / Full Forename(s)...... ………
Previous Name(s)...... …………..
Date of Birth ...... ……...../..…….…...../ 19………….
NMC/HPC PIN Number ………………………………..
CORRESPONDENCE DETAILS
Home Address ...... …………………….
...... ……………………...... Postcode………………………….……………………..
Home Telephone No…………………………………..Home email………………………………………………
Work Address (Area e.g. Ward) (in full) …………………………………………………………………………………
…………………………………………………………..Postcode…………………………………………………
Work Telephone No……………………………………Contact EMAIL ……………………………………………
Job role……………………………………………………
PLEASE PRINT YOUR EMAIL ADDRESS AS THIS HOW YOU WILL RECIEVE ALL COMMUNICATIONS
EMERGENCY CONTACT DETAILS
Contact Name: ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,……………….. Relationship ………………………………………..
Home Address ...... …………………….
...... ……………………...... Postcode………………………….……………………..
Home Telephone No…………………………………..

REGISTRATION DETAILS

Have you previously undertaken a course with us? YES/NO (please circle)
If YES, please indicate the following details of your last course/module:
Important you must provide the information on the highest academic qualification achieved
Qualification Subject Date
Parental Education
Do any of your parents have any higher education qualifications, such as a degree, diploma or certificate of higher education

:

DISCLOSURE AND BARRING SERVICE CHECK
In order to meet the required selection criteria for the course, the nominee must meet provide the following:
My Manager and I have signed below to confirm that I have had the appropriate Enhanced Disclosure and Barring Services check (DBS) and clearance:
Disclosure Number: ………………………………………………………………………………………
Issue Date:……………………………………………. Counter Signatory ……………………………
Signature……………………………Name (please print)………………………….…………………..
(Nominee)
Signature……………………………………………..Name (please print)…………………………….
(Manager)
If self- funding you will need to send the Original DBS document we will then return this to you by recorded delivery.
STUDENT DECLARATION
By signing this you are acknowledging:
  • The conditions set down in the Student Handbook issued to you
  • You have read the Notice on Data Protection which explains the use made by the University of your personal data
  • The University copying and distributing any or all of your work in any form and using third parties (who may be based outside the EU/EEA to monitor breaches of regulations, to verify whether your work contains plagiarised material, and for quality assurance purposes
  • The submission of the form will be taken as understanding the listed obligations and the giving of consent.
Plymouth University shares the student data with the Plymouth University Students’ Union for the purposes of membership to the union. Please tick this box if you do notwish to join Plymouth University Students’ Union or benefit from it’s facilities or services
SIGNATURE
I intend to take up a place one the module(s) indicated above and understand that this is a contracted place. On this basis I consent to the information collected and stored by the Plymouth University being used to inform:
  • Health Education South West of my failure to take up this place or attend the module(s) indicated and/or
  • My manager of the outcome.
I also agree that I will undertake any assignments associated with this/these modules.
Signed...... …….….. Date ...... …………………...... ………..
Please Note: due to unforeseen circumstances we may have to cancel courses, or alter details. We will advise you of any change as quickly as possible, however we strongly recommend that you check our website for up to date information before starting your course.

Guidance Notes for Completing Nomination Form

Ethnic and Disability Monitoring Forms

IMPORTANT: PLEASE NOTE

Thank you for making this application. In order to ensure that we are fair and consistent in our selection and monitoring procedures and so that we can monitor how well we meet our legal requirements, it is the policy of the University to require an Application Form and a Monitoring Form to be completed wherever possible.

The University of Plymouth recognises the benefits of having a diverse community of staff and students and as such is fully committed to equal opportunities. The information you provide will be treated in accordance with the University of Plymouth’s Data Protection Act Collection Notice - “Personal Information and Data Protection”. It will not be taken into consideration for your application.

Tick the boxes within the fields to complete the form.

Ethnic Origin:

As a requirement of the Race Relations Amendment Act (2000) we need to know your ethnic origin for the purpose of monitoring equality of opportunity to all ethnic groups, highlighting possible inequalities and enabling the implementation of action to remove any barriers and discrimination.

Please select from the categories below - these categories are approved by the Commission for Racial Equality and the Higher Education Statistics Agency:

White:

[10] _White

Mixed:

[41] _ White and Black Caribbean

[42] _ White and Black African

[43] _ White and Asian

[49] _ Any other mixed background

Asian or Asian British:

[31] _ Indian

[32] _ Pakistani

[33] _ Bangladeshi

[39] _ Any other Asian background

Black or Black British:

[21] _ Caribbean

[22] _ African

[29] _ Any other Black background

Chinese or other ethnic group:

[34] _ Chinese or any other Chinese background

[80] _ Other ethnic background

[90] _ Not known

[98] _ Do not wish to answer

Disability Monitoring Form

IMPORTANT: PLEASE NOTE

If you have a disability

The University is very supportive of students with disabilities, and year-on-year we are making adjustments to assist students with special arrangements. It may be that we have already put in place changes which will assist you - but unless we know what your needs might be, we cannot guarantee that that will be the case. If we can identify your needs sufficiently far in advance, of when you intend to start a course at the University, we are better able to put in place appropriate arrangements - or, if there is a health and safety issue or an issue about the expectations of students on the course, to advise you on alternative options. However, we may not be able to do so if we do not know in advance.

Please tell us about your disability

Please tell us about your disability, if you have one, by completing and returning the Disability Monitoring Form with your Application for Postgraduate Study. Please note that all offers are made on academic grounds.

You may be asked for additional information or invited to attend an interview with Disability Assist Services. This is in order that we can properly assess your individual needs and ensure that we have the best possible chance of meeting them. Please do provide any information requested and come in to see staff if asked to do so, since otherwise you - and we - could find ourselves in a position in which it is difficult or even unsafe for you to take up your place.

If you choose not to tell us about your disability

You may not wish to disclose your disability at this point. However, we may not be able to meet your individual needs if we do not have the opportunity to assess them in advance, and that could impact on your experience of the course or even your ability to take up your place.

You may feel that you would prefer to speak to someone confidentially about disclosure or that you require further information to help you decide. If this is the case, please telephone +44 (0)1752 587676 or email Disability ASSIST Services on

So please tell us about any disability - even if you do not think it will affect you while you are at the University - and respond positively to any requests for further details or for an information interview. If you do not do so, you may find yourself unable to take up your place or unable to complete the course because we have not been able to adequately to meet your particular needs._

Disability:

Please tell us if you have a disability, medical condition or dyslexia. Please select one of the following:
[A] _ No disability
[B] _ You have a social/communication impairment such as Asperger’s syndrome/other autistic spectrum disorder
[C] _ You are blind or have a serious hearing impairment
[D] _ You are deaf or have a serious hearing impairment
[E] _ You have a long standing illness or health condition such as cancer, HIV, diabetes, chronic heart disease, or epilepsy
[F] _ You have a mental health condition, such as depression, schizophrenia or anxiety disorder
[G] _ You have a specific learning difficult y such as dyslexia, dyspraxia of AD(H)D
[H] _ You have a physical impairment or mobility issues, such as difficulty using your arms or using a wheelchair or crutches
[I] _ You have a disability, impairment or medical condition that is not listed above
[J] _ You have two or more impairments and/or disabling medical conditions
Do you receive Disabled Students’ Allowance (DSA)?
[4] _ I have a disability and am in receipt of DSA
[5] _ I have a disability but do not receive DSA
[9] _ I have a disability but have not applied for DSA

_

Disability Disclosure:

YES
I agree to relevant information about my disability and/or support arrangements being disclosed to those lecturing and administrative staff who have a need to know.
In the event that I do not take up a place I understand that this information will be shredded within a reasonable period.
Signature: ......
Date: ......
NO
I do not agree to disclosure about my disability and understand that this may limit the support I receive.
I agree to inform Disability Assist Services if I reconsider this decision.
Signature: ......
Date: ......

SCREENING FORM FOR MENTORSHIP

Completed by Healthcare Organisation Representative

Completed by Plymouth University Representative

Name of Applicant …………………………………………………………………

Student Number if Known………………………………………………………….

Healthcare Organisation …………………………………………………………………

Preferred date of delivery …………………………………………………………..

(this can only be confirmed on site)

NMC PIN Number …………………………………………………………………..

______

APEL MENTORSHIP

Certificated Evidence confirmed ………………………………………………………..

Signed by PU/HCO representative ………………………………..Date …………………………………

Experiential Evidence confirmed ……….. ……………………………………………

Signed by PU/HCO representative ………………………………..Date …………………………………

Pre-Registration Mentorship course undertaken as part of the degree/diploma

Attendance Certificate and evidence of meeting entry criteria/Triennial Review confirmed

Signed by PU/HCO representative ………………………………..Date …………………………………

Full Taught Mentorship

No experience or certificated learning ………..………………………………………

Signed by PU/HCO representative ………………………………..Date …………………………………

Current Mentor Update Certificate (or evidence will be attending Mentor Update)

Signed by PU/HCO representative ………………………………..Date …………

h/plymadmin/cpd/mentorship/nomination form updated 2/7/14