Mersey Region Group for Health Training

Mersey Region Group for Health Training

IMMUNISATION & VACCINATION 2 DAY FOUNDATION COURSE

FOR REGISTERED NURSES

Hallmark Liverpool South Hotel (formerlyAlicia Hotel)Sefton Park, Liverpool

Tuesday 18thWednesday 19th July 2017

APPLICATION FORM

(Forms that do not have ALL the relevant information attached will be returned)

Closing Date: 18th June 2017 – there will be no refunds after this date

Title:….……… Forename ………..………………..…………………… Surname: …….………………………………………………….……

Work address: ………………………………………………………….....…………………………………………………………………..…….

……………………………………………………………………………… Postal Code ………………… Tel…………………………………

email……………………………………………………….……………. NMC No………………………………………………………………..

Date of RGN qualification ………………………………………

*Imms Mentor

Mentor’s Name ………………………………………… email address …………………………….

Tel:...... NMC No……………………….…..

*I confirm that I have attended a face to face immunisation training update within the last 3 years and ATTACH CERTIFICATE. In addition I confirm I have updated my skills annually through self audit and have been immunising for 2 years or more 

Dietary requirements: Vegetarian  Vegan  Gluten free  Other …………………………………..

PAYMENT DETAILS:- (represents 2 day course & all refreshments ( 9.00am – 4.35pm day 1 - 4.00pm finish day 2)

I enclose cheque for £250.00 payable to University of Liverpool 

I have paid by credit/debit card  Date paid …………………………………….

Card payments - Call 0151 794 6909, quote ref JXG10393 Code 6602 followed by your name

Please return completed application form to:-

Mrs Carmel Farrell

Universityof Liverpool

Mersey Region Group for Health Training

2nd floor Liverpool Women’s NHS Foundation Trust

Crown Street, Liverpool L8 7SS

Tel. No. 0151 702 4102 Fax 0151 702 4039

Following attendance at the course please see below:-

Before continuing you should undertake a Training Needs Analysis with your Mentor/Instructing Nurse Supervisor to identify the immunisations that you will be required to administer

Tick the box for each below.

1. / Diphtheria / 10. / Pneumococcal disease
2. / HaemophilusInfluenzae Type b (Hib) / 11. / Rubella
3. / Hepatitis B / 12. / Tetanus
4. / Influenza / 13. / Tuberculosis
5. / Measles / 14. / Human papillomavirus (HPV)
6. / Meningococcal disease Group B,C, ACWY. / Others:
7. / Mumps
8. / Pertussis
9. / Poliomyelitis

Carmel M. Farrell (Mrs)

Course Manager

Institute of Clinical Sciences

Mersey Region Group for Health Training

2nd floor

Liverpool Women’s NHS Foundation Trust

Crown Street, Liverpool L8 7SS

Tel: 0151 702 4102

Fax 0151 702 4039

Email:

CONTRACT OF TRAINING – Please complete below

Date of Theory Course …………………………………………

Expected mandatory completion of training is 6 months after attendance at the above theory course

NAME OF DELEGATE ………………………………………………………………………………………...

The above named has applied to attend the next RGN Immunisation Course

Following full attendance it is important that she/he completes all the practical training within the next 6 months. This will enable her/him to be signed off as competent and having completed the RGN Immunisation Training

If there are any problems or delays please don’t hesitate to get in touch with me for support

The practical training includes:-

The practical element is a very important part of immunisation training and failure to complete will mean that they will be unable to continue to immunise.

If there are any problems or delays please don’t hesitate to get in touch with me for support.

Signed by Practice Manager …………………………………………………………………

Please print full name ……………………………………………………………………………

email address …………………………………………………………………… Telephone no……………………………………

Practice Address………………………………………………………………………………………………………………………………

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