PRINCESS ROYAL SPINAL INJURIES CENTRE
SCI LINK-WORKER REGISTRATION FORM
Title: / Surname: / First Name:
Work Address:
Postcode: / Home Address:
Postcode:
Work Telephone:
Fax: / Home Telephone:
Mobile:
Work e-mail: / Home e-mail:

Current Area of Practice

(Please tick): / Employment Region
(Please tick):
Accident & Emergency
/ Yorkshire & Humber
ITU / HDU
/ East Midlands
Orthopaedics / West Midlands
Neurosciences / Eastern England
Paediatrics /
South & South-West
Rehabilitation / Community /
North-West & Wales
Other: (Please specify) /
Other: (Please specify)
PREVIOUS SCI EDUCATION AND EXPERIENCE
(Please indicate below as appropriate and give further details on page 2)

Level 4

/ I have previously undertaken a specialist course in the care and management of people with spinal cord lesions in association with a local Spinal Cord Injuries Centre.
I have previously been employed within a Spinal Cord Injuries Centre for at least 12 months.
a

Level 3

b / I have previously undertaken a specialist module relating to the care and management of people with spinal cord lesions within a post-registration course which was facilitated by a local Spinal Cord Injuries Centre.
I have previously been employed within a Spinal Cord Injuries Centre for at least 6 months

Level 2

/ I have previously attended a local / regional Spinal Cord Injuries Study Day in the last 3 years facilitated by a local
Spinal Cord Injuries Centre / Link Worker.
Level 1 / It has been more than 3 years since my last attendance at a local / regional Spinal Cord Injuries Study Day facilitated by a local Spinal Cord Injuries Centre / Link Worker.
Level 1
(Associate) / I have an interest in promoting best practice in the management of people with SCI but I have received no formal education in the care and management of people with spinal cord injuries.
Please give details of education and training received including dates of completion and any SCIC placements undertaken:
Are you currently acting as a Spinal Cord Injury Link-Worker within your own area of practice? / YES / NO
Are you familiar with the Link-Worker expectations? / YES / NO
Are you supported by your Ward / Unit / Departmental Line Manager? / YES / NO
Name of Supporting Manager:
Are you able to advise on SCI management in other areas of practice? / YES / NO
Other areas of practice that you are able to advise within:
Are you aware of other SCI Link-Workers active within your Trust? / YES / NO
Names of other SCI Link-Workers in your Trust that you are aware of:
Will you permit the release of your work contact details within the network to other registered SCI Link-Workers?
(Please circle as appropriate) / YES / NO

Please return completed form to Paul Harrison, Clinical Development Officer, Princess Royal Spinal Injuries Centre, OsbornBuilding,

Northern GeneralHospital, Sheffield. S5 7AU.

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