West Midlands Strategic Health Authority

West Midlands Public Health Practitioner
Development Scheme2012-13
Cohort 3Application Form
to be returned to Sally Jamesby 28th September 2012
Author:Sally James, Public Health Workforce Specialist
Date:1st August 2012 / Version:01
Publication/ Distribution:
Workforces across the West Midlands, who promote, protect, advocate for, develop and improve health with local communities and groups. They may be based in NHS public health teams, local government, primary care or any of the health and social care organisations including voluntary and third sectors.
Purpose Summary of Document:
This application form should be submitted by public health practitioners to be considered for recruitment onto theWest Midlands Public Health Practitioner Development Scheme. The Scheme aims to provide support to public health practitioners in developing portfolios of evidence against the UK Public Health Register (UKPHR) Public Health PractitionerStandards.
Applicants must have read and accepted the related Public Health Practitioner Development Scheme Framework &Guidance Document before submitting an application.
Selection Criteria
Applicants must be able to demonstrate:
  • Employment within the NHS West Midlands geographical area
  • Approximately two years’ public health experience, usually having occupied a public health practitioner post at NHS Agenda for Change band 5 and above or equivalent in other sectors; operating at Level 5 or above on the Public Health Skills & Career Framework (PHSCF)
  • Self-assessment against the Public Health Practitioner Standards.Applicants must be able to demonstrate (through completing the self-assessment form)a broad range of relevant experience with only a few gaps,each of which should be relatively easy to address within the timescale for portfolio submission
  • A signed commitment to completing a portfolio against the Public Health Practitioner Standards for Registration in the timescale specified. This must be a genuine commitment to completing a portfolio by the end of December 2013 at the latest
  • A signed commitment from their line manager for active support and encouragement through practitioner attendance at learning sets, writing time for portfolio development and relevant CPD events to address “gaps”, to a maximum of 8 days in the period specified
The signed application form commits the practitioner to submitting a completed portfolio by December 2013.
Application Form
  • Section A: applicant details
  • Section B: supporting information
  • Section C: for completion by Line Manager
  • Section D: for completion by Director of Public Health
All sections must be completed and posted or scannedandemailed,together with a completed self-assessment form by 28th September 2012as follows:
Sally James
Public Health Workforce Specialist
Workforce Deanery
NHS West Midlands
St Chads Court
213 Hagley Road
Birmingham B16

West MidlandsPublic Health Practitioner Development Scheme 2012-13

Cohort 3Application Form

Please complete all sections below & attach a completed self-assessment:

Section A: applicant details

Name:
Job Title:
UK Public Health Skills and Career Framework level or Agenda for Change / KSF Banding of current post(or equivalent):
Length of time in current position:
Employing Organisation:
Employer’s Address:
Postcode:
Telephone number:
Email:
Mobile phone number:

Your personal information will be held and used in accordance with the Data Protection Act 1998. NHS West Midlands will not disclose such information to any unauthorised person or body but where appropriate will use such information in carrying out its various functions and services.

(continued…)
Section B: supporting information

Please detail in no more than 200 words why you are applying to the Public Health Practitioner DevelopmentSchemeCohort 3and any progress you have made to date on developing your portfolio:
Using the baseline self-assessment form, please describe belowany competence gaps you have already identified your plans to address them:
Competence Gap
(Area and Standard number referencee.g. Area 4, Standard 12) / Suggested method to address gap (i.e. training, shadowing etc.) / Target completion date

Terms and Conditions:

In submitting an application to the Scheme applicants will have read and fully understood the Public Health Practitioner Development Scheme Framework & Guidance Document. Applicants must be committed to full participation in all elements of the Scheme and to work towards developing their portfolio within the timescale specified.

Declaration:

I confirm that the information I have given is accurate, and should I be accepted onto the Scheme I agree to abide by its principles and to participate fully, including in the evaluation process.

If accepted onto the Scheme, I will attend the applicant in-depth workshopin October 2012 (date to be confirmed)

Applicant Signature
Date

Please ensure that your Line Manager and Director of Public Health complete the following sections before submitting your application

Please also attach a completed self assessment form to this application

(continued…)

Section C: for completion by Line Manager

Please provide belowa signed written statement of support for the applicant (not more than 200 words), detailing the ways in which you feel they are suitable and ready for the Scheme. By completing the statement, it is assumed that you fully support the applicant’s participation in the Public Health Practitioner Development Scheme(should they be accepted) and confirm that they will be afforded the required time off, study leave etc. (up to a maximum of 8 days) to ensure maximum participation in the Scheme and its constituent parts.

Please acknowledge the competence gaps identified and provide any additional and relevant information.

Line manager details:

Signature / Position
Print name / Date
Email / Phone
number

Section D: for completion by Director of Public Health

Please signbelowto confirm your support for the applicant’s participation in the Public Health Practitioner Development Scheme(should they be accepted). Please also include any additional comments you may wish to make.

Signature / Position
Print name / Date
Email / Phone
number
Any additional comments from DPH:

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