SUPPLEMENTARY INFORMATION FORM - Midwifery

SUPPLEMENTARY INFORMATION FORM - Midwifery

Full Name:

Do you have any previous nursing or midwifery training? Yes  No 
If yes, you must advise us of any complete or incomplete training
Type of Programme: Date From: To:
Have you lived abroad in the last 3 years)? Yes  No 
If you have lived outside of the UK for a period of six months or more in the last 3 years please provide us with full details below:
Date From: To: Country:
Do you have any convictions, cautions, reprimands or final warnings which would not be filteredin line with current guidance? For more information about what you should declare, please see the DBS Filtering Guide:
https://www.gov.uk/government/publications/dbs-filtering-guidance
I have read and understood the above and do NOT have anything to declare:
I have read and understood the above and DO have something to declare:
I enclose a statement providing the date(s), nature of offence(s), outcomes (i.e. fine, sentence - caution/warning, etc), together with a brief description of the events surrounding the incident(s) OR
I have already provided these details previously:
Placements and Localities: Please indicate your choice of academic teaching area (Please tick one)
Lansdowne Campus – Bournemouth (Sept 2015) Portsmouth Branch Campus (Feb 2016)
During training you will gain clinical experience in a variety of settings (placements) in hospitals and out in the community. Midwifery students will be based in one localityfor the duration of their three years at university. Students will be expected to travel to health care facilities not only in the major towns, but also sometimes in the more rural settings. You will be expected to find your way to these different places, either by public transport or your own transport and, in some cases, travel distances of up to 40 miles in each direction to reach them. Please indicate your first and second choice of clinical locality by writing 1 and 2 in the boxes below:
Clinical Placements in and aroundBournemouth/Poole. Academic teaching at Lansdowne Campus in Bournemouth
Clinical Placements in and aroundDorchester. Academic teaching at the Lansdowne Campus in Bournemouth
Clinical Placements in and aroundSalisbury. Academic teaching at the Lansdowne Campus in Bournemouth
Clinical Placements in and aroundYeovil. Academic teaching at the Lansdowne Campus in Bournemouth
Clinical Placements in and aroundWinchester. Academic teaching at the Lansdowne Campus in Bournemouth
Clinical Placements in and aroundPortsmouth. Academic teaching at Portsmouth St Mary’s Health Campus
Clinical Placements in and aroundBasingstoke. Academic teaching at Portsmouth St Mary’s Health Campus
Clinical Placements in and aroundIsle of Wight.Academic teaching at Portsmouth St Mary’s Health Campus
If you accept an offer in a certain locality, you will remain in this locality for the duration of your training; however, in exceptional circumstances we do reserve the right to amend your offered locality if the need arises.
Accommodation and Transport
When I commence my training I will:Continue living at home Apply for Uni/Hospital Accommodation 
To reach placement, I will use the following: Own Car/Motorbike Bicycle Public Transport

Please tick the box confirming all information supplied is true, accurate and complete.

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