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Full IP Course
Application Form C
Postgraduate Programmes in Medicines Management
School of Pharmacy, Keele University
Independent Prescribing Preparatory Course for Pharmacists
Designated Supervising Medical Practitioner (DMP)
Nomination and Endorsement Form
Parts 1 and 2 of this form should be completed by the DMP in block print. The declaration should be signed and dated. Appendix 1 provides an overview of the DMP's role during the Course. It is an extract from the DMP Handbook that DMPs receive when pharmacists start the course.
NB The completed form should be sent by the pharmacist applicant to Keele University with the University application form.
Part 1
Name:
Surname:
First name:
Professional Qualifications and Registration Number:
Contact Address: (including department, if relevant)
Contact Telephone Number(s):
E-mail Address:
Part 2
We would be grateful if you could supply the following information. This will ensure that the Department of Health’s (DH) criteria for supervision of the twelve-day learning in practice period for this Independent Prescribing Preparatory Course are met. Please circle YES or NO as appropriate.
1Are you a registered medical practitioner who has had at least 3 years medical, treatment and prescribing responsibility for a group of patients/clients in relation to the clinical condition(s) for which the trainee independent prescriber (TIP) is going to use their independent prescribing skills?
YESNO
AND
2Are you:
Within a GP practice and either vocationally trained or in possession of a certificate of equivalent experience from the Joint or Postgraduate Training in General Practice?
YESNO
OR
A specialist registrar, clinical assistant or a consultant within a NHS Trust or other NHS employer?
YESNO
AND
3Have you the support of the employing organisation or GP practice to act as the DMP who will provide supervision, support and opportunities to develop the TIP’s competence in prescribing practice?
YESNO
AND
4Have you some experience of training in teaching and/or supervision in practice?
YESNO
If you are not an Approved Training Practice/Institution then please outline your experience of teaching, supervision and assessment of students in the box below.
Declaration
I confirm that I have agreed to supervise the applicant in the 'learning in practice' element of the Course, in the clinical area in which the pharmacist intends to prescribe independently immediately on qualification, for a period of learning in practice of at least twelve days:
Signature………………………………………….Date…………………
Keele University Full IP Course: DMP Nomination and Endorsement
Adapted in part from an original form produced by London, Eastern and South East Specialist Pharmacy Services June 2003