UNIVERSITY OF NOTTINGHAM

DIVISION OF NUTRITIONAL SCIENCES

Pre Placement A form

Name:
Course:
University:

Contact details

Address

Telephone

Email

DBS number: ______

DBS date of issue:______

Occupational Health Screening:

This student has participated in the Occupational Health programme at Nottingham University and has received clearance to commence placement.

Sharing of pre placement form details – please tick one box only
Information to be shared with the dietetic manager and team 
Information to be shared with the dietetic manager only (please discuss this option with your tutor) 

Course progression summary (eg stage of University training)(UG or PG student, year of study, first degree if applicable):

What modules have you undertaken in the past academic year

Academic performance (to be completed by the student):

To date most of my marks have been:

70 and above

ranging from 60-70

Between 50-60

Between 45-50

Comments:

Personal statement: (Please write a summary statement about yourself. You may wish to highlight some of your strengths, personal attributes and any previous experiences that you feel are relevant to your placement).

How would you describe yourself? Please circle the description you most identify with. Please share some examples that would help illustrate each statement.

I see myself as shy/not outgoing/not particularly shy/outgoing

  • I tend to be very organised and methodical in my approach to completing work/I prefer to work under pressure and to tight deadlines.
  • I tend to come up with new ideas and make suggestions / I feel more comfortable when I am asked to do something with clear guidelines.

LEARNING STYLE

When I am learning I prefer to: (please circle the description you most identify with)

  • watch someone else first, then have time to think & prepare before I have a go
  • give it a go & see how it turns out
  • understand everything (the activity itself, its context and the theory behind it) before I do anything
  • only do things if they seems relevant & practical; theories & models are of less interest than getting things done in a way that works

Please complete a learning style questionnaire such as Honey and Mumford and document what your learning preference was highlighted to be:______

Please share some examples that would help illustrate your learning preference

Is English your first language? Yes/No

Do you identify yourself as having a disability? Yes/No

If yes please give details and a brief outline of your specific training needs

Drawing on the information that you have given above, please summarise any specific training needs that you would like support with? (eg you need support to build confidence talking to patients, or you feel nervous about being in the hospital environment?)

Any other factors that might impact on your training, that may need to be considered by your practice trainer?

Consideration of the learning outcomes for the A placement.

Use the following boxes to highlight those areas that you are confident about, any that you feel you need to develop and any actions you are already taking/ would like to take to help you develop.

KNOWLEDGE

Strengths:

Areas for improvement:

Action points:

COMMUNICATION

Strengths:

Areas for improvement:

Action points:

PROFESSIONAL PRACTICE

Strengths:

Areas for improvement:

Action points:

NAME OF STUDENT
SIGNATURE OF STUDENT
NAME OF TUTOR
SIGNATURE OF TUTOR
DATE

Process for completion of form:

  1. Complete the formprior to your pre placement meeting with your placement tutor. Bring the competed form to your meeting
  1. After completion, a copy of this form should be:
  • Retained by the university
  • Sent to the student training lead at your placement site and
  • A copy should be held by the student in their portfolio.

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Revised September 2016