PLACEMENT AUDIT INFORMATION - ALLOCATIONS OFFICE

In addition to completing the electronic audit, link lecturers and placement staff are asked to complete the following form for return directly to the Allocations Office* . Please be mindful that this document in itself is NOT an actual audit, it is a record that the formal audit has been completed along with supplementary information needed to maintain the allocation management system in use by the Allocations Team.

Placement Name______

Organisation / Trust Name ______

Full Address______

______

______

Postcode______Tel Number______

University Link Lecturer______

Placement Contact (this is the______

person, usually termed the Learning Environment Manager (LEM), to whom all correspondence re student allocations will be addressed)

Email Address of Contact ______

Type of Experience(if mental ______

health placement please indicate if

appropriate for Acute, Recovery or Over 65 programme rotations)

Maximum number of students on NMC approved programmes that can be supported at

any one time (please note if this is reducing since the previous audit, chief nurse or approved deputymust

countersign agreement)

Placement Suitable for (please tick all that apply – please do not insert numbers)

Stage 1 Midwifery Students

Stages 2&3Post-Registration Students

Audit Date ______Next Audit Due ______

Action Plan Dates ______

Signature of a member of the audit team ______Date ______

Signature of Chief Nurse or Approved ______Date ______

Deputy (if reducing numbers)

Office Use Only – Is this placement organisation signed up to the HEY&H LDA or does it have a signed Partnership Agreement with the Univeristy of York? YES NO Done Date______

* please return both pages to: Sarah Wooffitt – Allocations Assistant, Dept of Health Sciences, Area 5, Seebohm Rowntree Building, University of York, Heslington, York YO10 5DD

Last reviewed 27.10.17 sjw

MENTOR INFORMATION (please complete and sign either section A or section B)

SECTION A If the organisation’s mentor register is available to view on-line at the point of audit, please complete the following:-

I verify that the information held on the mentor register is accurate (with the following amendments if applicable) and can confirm that there are sufficient qualified and updated mentors to meet requirements for mentoring the students agreed at audit.

Name (print): ………………………………………..…………. Signature: ………………………………………………. Position in Organisation: ………………..………………………….

Mentor Name / Reason for Change / Qualification details and further information e.g. if new to area where did they work previously or if left, where have they moved to? / Office
Use

SECTION B If it was not possible at audit to access the mentor register on-line, it is essential that you fully complete the following table with all details so the register can be verified through the appropriate administrator (the Allocations Office will send this to the relevant person).

Mentor Name

/ Professional qualifications / Mentor Qualifications
(please refer to mentor equivalencies) / Full-time/part-time (please give as whole time equivalence) / Sign-off
mentor?
(yes/no) / Date of last mentor update / Date next triennial review meeting due / If new to the area, please indicate where you previously mentored students / For Office Use Only

Statement by Placement Representative at Audit

I confirm I have checked that the information in Section B is an accurate statement of fact.

Name (print): ………………………………………..…………. Signature: ………………………………………………. Position in Organisation: ………………..………………………….

Last reviewed 27.10.17 sjw