application form cpd modules awarding level m credits · application form cpd modules awarding ......

Application Form CPD Modules Awarding Level M Credits Thank you for your interest in the Continuing Professional Development Level M Modules. This form cannot be used to apply for level 2 or 3 modules, Independent/Supplementary Non-Medical Prescribing Modules (Levels 3 and M), short courses or other BSc or MSc/PG Dip programmes. If you would like to apply for one of these, please visit our website www.city.ac.uk/cpdapply

The application form must be completed in English. Any supporting documents not in English must be accompanied by a certified translation. Please complete all sections in black ink and print clearly. It will take us longer to process your application form if information is missing.

Module Information

Preferred Start Date: We will endeavour to provide you with a place on the start date you request. If this is not possible we will contact you to offer an alternative date.

Funding Information

NHS London Contracting Trust Sponsored: Please see list of NHS London Trusts that have a formal agreement with City University London at www.city.ac.uk/cpdapply Please tick the appropriate box depending on whether your Trust has an agreement with City University London. Please ensure that your Line Manager/Training Co-ordinator and Trust Education Lead complete the relevant sections of this form.

Self Funded: If you are paying your own fees, please complete the Notification of Fees form (last page of this application form). If you are paying by cheque, please remember to enclose this with your application form.

Fully Employer/Non NHS London Funded: If your employer is paying your fees, please arrange for your budget holder to complete the Notification of Fees form in order that we can send them an invoice (last page of this application form).

Part Self Funded/Part Employer or Non NHS London Funded: If you are going to be part funded by your employer, and part self funding, please complete the Notification of Fees form (last page of this application form). If you are paying by cheque for your part of the fee, please remember to enclose this with your application form. We will send an invoice to your employer for their part of the fee.

References

If you do not have a degree we will require two references. Please see details on pages 9-12 of this application form. Please ask your referees to complete and return the references to the CPD Administration Team (details below) in a clearly marked envelope. One should be an academic reference from your most recent studies and the other reference from your line manager in support of your application. We will also require a copy of your degree certificate and transcript of your training, NMC PIN (if applicable) and confirmation of funding.

Application Process

In order for us to ensure your application is processed in due time, please ensure we receive your form at least 6 weeks before the module is due to commence. Please send your completed application form to the address below.

Alternatively you can fax your completed application, marking it for the attention of CPD Administration: Fax: +44 (0)20 7040 5808.

If faxed – please ensure you subsequently post the hard copy of the application form to the address below.

To find out if a module is suitable for you or for further information please contact:

Sonia Brown Telephone: 020 7040 5934/5828 Email: [email protected]

What happens next?

We aim to acknowledge all applications within 14 working days. If you have not heard from us during this time, please contact the CPD Administration Team via [email protected] or by telephone on + 44 (0) 20 7040 5828. We will send confirmation on receipt of your application, in writing, to your correspondence address. Please note: you are advised to keep a copy of your completed application form for your records.

School of Community and Health Sciences

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Tel: + 44 (0) 20 7040 5828, Fax: + 44 (0) 20 7040 5808, Email: [email protected] Administration Team, School of Community and Health Sciences, City University London, Health Building,Northampton Square, London EC1V 0HB


Application FormCPD Modules Awarding Level M Credits

Please complete this form using black ink, write neatly and clearly in order for us to process it promptly. All sections must be completed.

Module Information (To be completed by all applicants)For details of the term(s) that modules are due to commence please refer to timetables at www.city.ac.uk/lifelong *We will endeavour to provide a place on the requested dates. Should this not be possible, you will be offered the next available date.**Credits can only be awarded if the assessment is undertaken and passed.

Module Code Module Title Preferred Start Date*Undertaking module as Attendance only or Submitting Assessment?** (please delete item not applicable)

Attendance/Submitting Assessment




Personal Information (To be completed by all applicants)Have you studied at City University London in the past?

Yes o No o

If ‘Yes’ please state your Student Number (if known)

Title

Mr/Miss/Mrs/Ms/Dr/Other ..................

First Name Surname Known as Name (if applicable)

Previous Name(s) (if changed) Date of Birth

D D/M M/Y Y Y Y

Gender (please tick)M o F o

Permanent Address

..............................................................................................

..............................................................................................

..............................................................................................

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............................................ Postcode ............................

Correspondence Address (if different to permanent address: not a work address)

..........................................................................................................

..........................................................................................................

..........................................................................................................

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............................................ Postcode ........................................

Tel No. (Home) .................................................................

Tel No. (Work) ........................................ Ext: ................

Tel No. (Mobile) .................................................................

Personal Email Address

Nationality (please state dual nationality) ...........................................

Country of Permanent Residence .........................................................

Country of Birth ..................................................................................

If a holder of a UK entry visa please state conditions of entry

..........................................................................................................

Date of Arrival into the UK (dd/mm/yyyy) .............................................

Passport Number ...............................................................................(if you are not a UK/EU citizen)

Next of Kin (Name) Next of Kin (Relationship) Next of Kin (Contact Number)

NMC PIN (If a registered nurse, midwife or health visitor) NMC PIN Expiry Date

D D/M M/Y Y Y Y

Work Status

Full Time o Part Time o

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Marketing Monitoring (To be completed by all applicants)How did you hear about the programme?

City University London Website o

Other Website o Advertisement o Letter o Email o

Previous/Existing Student o Referral o Prospectus o Event o Other o

Present or Most Recent Employment (To be completed by all applicants)Post Held (your job title) Speciality (e.g. adult,

paediatric) Department/Ward (if applicable)

Date of Appointment (to your current post)

D D/M M/Y Y Y Y

Name of Employer (if applicable, the name of the hospital, practice or agency you work for. Details of Trust are asked elsewhere on this form)

Summary of Duties/Responsibilities (a brief outline of what your job entails)

Employment History (To be completed by all applicants)Please list previous posts held over the last 5 years (most recent first). Agency posts must be marked and overseas employment should be included. Please use a separate sheet if required.Employer’s Name and Address Grade/Post From To Reason for Leaving

English Language Qualifications (To be completed by applicants if English is not your first language)If English is not your first language, you must show evidence that your command of the English language is suitable for entry to degree-level studies. A pass in one of the following qualifications is the minimum expectation of City University London: IELTS Test of the British Council at 7.0 TOEFL Internet based total of 107 or above.Please indicate which tests you have taken, or have registered to take. Date Awarded Awarding Body Qualification Grade

D D/M M/Y Y Y Y


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Education and Qualifications (To be completed by all applicants)Academic/Professional Education. Start with the most recent and give your Academic and Professional qualifications. List all the courses you have attended after secondary school. Include courses undertaken whilst you were working. These can include degree, diploma and any relevant modules, short courses and study days.

Educational Establishment(s) Attended Subject Level Grade Date Completed

Declaration of a Criminal Record (To be completed by all applicants)

Have you been through the Criminal Records Bureau Enhanced Disclosure process in relation to your current employment?

Yes o No o Signed ....................................................................................................................


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Statement of Support (To be completed by all applicants. This will help us to consider your application form.)

You should either attach a supporting statement or use this section in support of your application including the reasons for your choice of module and how your experience, personal qualities and qualifications make you a suitable candidate.


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Funding Information (To be completed by all applicants)

Please see guidance notes and list of NHS London Trusts at www.city.ac.uk/cpdapply Please Tick

I am sponsored by an NHS London Trust that does have a formal agreement with City University London o

I am sponsored by an NHS London Trust that does not have a formal agreement with City University London o

Self Funded o

Fully Employer/Non NHS London Funded o

Part Self Funded/Part Employer or Non NHS London Funded o

Ordinances and Regulations of City University London

As a student of City University London you undertake to observe and comply with the Ordinances and Regulations of the University and that, to the best of your knowledge, the information provided is correct and complete. Information about City University London’s Ordinances and Regulations is available at: www.city.ac.uk/aboutcity/governance/ordinances_and_regulations

Data Protection Act 1998

We are collecting this information to process your application and to support your study at City University London in accordance with the Data Protection Act 1998. We may pass information about your progress to other organisations such as a sponsor. Further details in relation to the use of personal data can be found at www.city.ac.uk/dataprotection If you would like more information or have concerns please contact the Head of Information Compliance and Policy via [email protected]

Financial Terms and Conditions

All fees are payable prior to commencement of the module. You and your sponsor (if applicable) will remain liable to pay any outstanding debt, interest or administrative charges that may be levied in respect of any delay in the payment of fees. If you leave employment with your sponsor you will remain liable to pay any outstanding debt, interest or administrative charges that may be levied in respect of any delay in the payment of fees. Legal action may be taken to recover any amount overdue. The University may use external agencies to assist in the collection of fees if you fail to pay by the due dates. Any non-payment of fees will result in the removal of access to computing and library services and will necessitate in your withdrawal from the University.

Cancellation Charges for Self Funded/Employer or Non NHS London Funded All cancellations must be done in writing or by email to [email protected] Cancellations must be received 4 weeks prior to the start of the module. Please note we do not accept telephone cancellations. If you do not attend the module and have not previously informed us, fees are non-refundable.

If you are offered a place and cannot attend or wish to defer, please contact the CPD Administration Team at [email protected]

NB: Please note that fees are subject to change.

Declaration (To be completed by all applicants)

I confirm that I have read and understood and agree to the Ordinances and Regulations of City University London and the Financial Terms and Conditions. I agree that information given, both in writing and verbally, may be used by the University in accordance with the Data Protection Act 1998.

Applicant’s Signature Date D D/M M/Y Y Y Y

Declaration and Agreement to Support Study (To be completed by Line Manager/Training Co-ordiantor, if applicable.)

I am confident that the applicant meets the selection criteria for the module requested. I agree to treat all performance and attendance data provided to me by City University London in accordance with the Data Protection Act 1998 in confidence.

Name of Trust (if applicable)

PositionLine Manager/Training Co-ordinator’s name (please print)

Line Manager/Training Co-ordinator’s signature

DateD D/M M/Y Y Y Y


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Employer Authorisation if Applicant is Not Self Funding (To be completed by Budget Holder/Trust Education Lead)

I confirm that I have read and understood and agree to the Financial Terms and Conditions. I agree to treat all performance and attendance data provided to me by City University London in accordance with the Data Protection Act 1998 in confidence.

NHS London Trust Sponsors OnlyOn behalf of my NHS London Trust, I agree to sponsor the student for the fees of the module(s).

Other SponsorsI confirm that I will agree to sponsor the student for the amount detailed in invoices provided by City University London.

Name of Authorised Budget Holder or Trust Education Lead

Sponsor’s Position

Sponsor’s Signature Date D D/M M/Y Y Y Y

Authorised Joint NHS London Trust/City University London Stamp(If your Trust has a formal agreement with City University London, please use your official stamp.)

NHS London Trusts that do not have a formal agreement with City University London

If you are applying via an NHS London Trust that does not have a formal agreement with City University London we will need to contact the Trust Education Lead. A list of Trusts that have a formal agreement can be found at www.city.ac.uk/cpdapply

Name of NHS London Trust

Education Lead’s Name (please print)

Education Lead’s Email Address

Education Lead’s Telephone Number and Extension

Address ......................................................................................................................................................................................................................

......................................................................................................................................................................................................................

......................................................................................................................................................................................................................

........................................................................................................................................ Postcode ........................................................


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Equal Opportunities Monitoring Form(To be completed by all applicants)

Thank you for providing this information which on receipt will be detached from your application and used only for monitoring purposes.

City University London, confirms its commitment to equal opportunities in all its activities. The University must not discriminate against an applicant on any of the following grounds: political belief, gender, sexual orientation, age, disability, marital status, race, nationality, ethnic origin, religion or social background.

The information you give is in confidence and will not be seen by or made known to any sector. It will be used only to monitor the operation of the Equal Opportunities Policy and will not be made available to Admissions Tutors.

Our equality and diversity policy can be found at www.city.ac.uk/hr/policies/equality-diversity/equality-diversity

Please indicate with a tick where appropriate

Ethnic OriginIn order for us to assist in our Equal Opportunities monitoring please tick one of the following boxes, which best describes your Ethnic Origin.

o10 White

o21 Black or Black British Caribbean

o 22 Black or Black British African

o29 Other Black background

o 31 Asian or Asian British Indian

o 32 Asian or Asian British Pakistani

o 33 Asian or Asian British Bangladeshi

o34 Chinese

o39 Other Asian background

o41 Mixed White and Black Caribbean

o42 Mixed White and Black African

o 43 Mixed White and Asian

o49 Other Mixed Background

o80 Other Ethnic Background

o90 Not Known

o98 Information Refused

If you have a disability or a long term medical condition we can try and offer study and examination facilities which meet your needs. (Please contact the Disability Officer to discuss.)

Do you have a disability? Yes o No o

Tick one of the following boxes if you wish to declare a disability or long term medical condition.

o01 Dyslexia or other specific learning difficulty

o02 Blind/partially sighted

o03 Deaf/hearing impairment

o04 Wheelchair user/mobility difficulties

o05 Personal care support

o06 Mental health difficulty

o07 Unseen disability, e.g. diabetes or epilepsy

o08 Multiple disabilities

o09 Other disability

o10 Autistic Spectrum Disorder

o 98 Information not sought

I agree that the information given on this form may be processed by City University London in accordance with the Data Protection Act, in particular, for the purposes of the equal opportunities monitoring. I agree to the storage of this information on manual or computerised files.

Signature Date

D D/M M/Y Y Y Y


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References (Page 1 of 2) Applicant’s Name Programme of Study

To the applicantPlease print the two reference forms and forward them to your two referees. One referee should be from your current or last employer (e.g. line manager). The other reference should be a character reference from a previous employer e.g. line manager or work colleague. We cannot accept references from relatives or friends.

Upon receipt of the completed, sealed references please forward them, in a clearly marked envelope to:CPD Administration, School of Community and Health Sciences, City University London, Philpot Street, Whitechapel, London E1 2EA

To the refereeThe above named person has applied to be admitted to postgraduate module(s) at City University London and has given your name as a referee. We would be most grateful if you would provide us with a reference on the applicant’s academic and general ability to undertake the proposed programme of study named above. Please complete the questions on this form or attach a written statement of reference on letter headed paper. Your reply will be treated in confidence by the University.

ImportantPlease place the reference in an envelope which should be sealed and signed across the seal. The signature should be covered with clear tape on it to ensure confidentiality. The sealed envelope should be returned to the applicant who will forward it to the University.

How long have you known the applicant and in what capacity?............................................................................................................................................................................................................................................

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What do you consider to be the applicant’s main strengths and weaknesses?............................................................................................................................................................................................................................................

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Bearing in mind the specialism chosen, what is your opinion of the applicant’s suitability for this programme?............................................................................................................................................................................................................................................

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Is there any information which you feel is relevant? E.g. expected examination results. Please continue on a separate sheet if necessary.............................................................................................................................................................................................................................................

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References (page 2 of 2)

Please rate the applicant with respect to the following categories

Outstanding (top 5%) Above Average Average Below Average

Academic Potential

Analytical Ability

Originality

Capacity for Fluent and Logical Communication (oral)

Capacity for Fluent and Logical Communication (written)

Diligence

Overall Rating

Name of Referee Position

Telephone Number Email Address

Company Name:

Company Address: .....................................................................

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..................................................................................................

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............................................ Postcode ....................................

Authorised Stamp (If unavailable please provide a compliment slip or sample of headed paper)


Referee’s Signature Date D D / M M / Y Y Y Y

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References (Page 1 of 2) Applicant’s Name Programme of Study

To the applicantPlease print the two reference forms and forward them to your two referees. One referee should be from your current or last employer (e.g. line manager). The other reference should be a character reference from a previous employer e.g. line manager or work colleague. We cannot accept references from relatives or friends.

Upon receipt of the completed, sealed references please forward them, in a clearly marked envelope to:CPD Administration, School of Community and Health Sciences, City University London, Philpot Street, Whitechapel, London E1 2EA

To the refereeThe above named person has applied to be admitted to postgraduate module(s) at City University London and has given your name as a referee. We would be most grateful if you would provide us with a reference on the applicant’s academic and general ability to undertake the proposed programme of study named above. Please complete the questions on this form or attach a written statement of reference on letter headed paper. Your reply will be treated in confidence by the University.

ImportantPlease place the reference in an envelope which should be sealed and signed across the seal. The signature should be covered with clear tape on it to ensure confidentiality. The sealed envelope should be returned to the applicant who will forward it to the University.

How long have you known the applicant and in what capacity?............................................................................................................................................................................................................................................

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What do you consider to be the applicant’s main strengths and weaknesses?............................................................................................................................................................................................................................................

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Bearing in mind the specialism chosen, what is your opinion of the applicant’s suitability for this programme?............................................................................................................................................................................................................................................

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Is there any information which you feel is relevant? E.g. expected examination results. Please continue on a separate sheet if necessary.............................................................................................................................................................................................................................................

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References (page 2 of 2)

Please rate the applicant with respect to the following categories

Outstanding (top 5%) Above Average Average Below Average

Academic Potential

Analytical Ability

Originality

Capacity for Fluent and Logical Communication (oral)

Capacity for Fluent and Logical Communication (written)

Diligence

Overall Rating

Name of Referee Position

Telephone Number Email Address

Company Name:

Company Address: .....................................................................

..................................................................................................

..................................................................................................

..................................................................................................

..................................................................................................

............................................ Postcode ....................................

Authorised Stamp (If unavailable please provide a compliment slip or sample of headed paper)


Referee’s Signature Date D D / M M / Y Y Y Y

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Notification of Tuition Fees Payable (This is not a VAT invoice)This completed form should be returned (with a covering letter from your sponsor if they are paying ALL/PART of your fees) to CPD Administration Team, School of Community and Health Sciences, City University London, Health Building,Northampton Square, London EC1V 0HB

Course Details Student Name and AddressStudent Number

Code

TitleFee Payable

Start Date

In the unlikely event that the fee above is incorrect, we reserve the right to charge you the correct amount and to require payment of any shortfall as a condition of completing your registration.

The payment options are as follows (please tick the method by which you wish to pay and complete the necessary details):

1. o I enclose a cheque (£) for the Full amount made payable to ‘City University London’

2. o My sponsor has agreed to pay the Full amount agreed for the above course/module(s), so please send an invoice to my sponsor as follows:

Contact Name .............................................................................. Job Title ...............................................................................

Company ..................................................................................................................................................................................

Address ..................................................................................................................................................................................

Postcode ................................................... Telephone Number ..........................................................................................

Student’s Signature ..................................................................................... Date ....................................................................

Please note that we will not be able to complete your registration if you do not enclose a letter of confirmation from your sponsor. You will be liable for payment of fees should your sponsor fail to provide payment.

3. o I authorise the University to charge my credit card/bank account with the Full amount as agreed in respect of my fees

The University accepts payment by Maestro, Visa Delta, Access, Visa and MasterCard. We do not accept American Express or Diners Club cards.

Card Holder Name (as shown on card) .....................................................................................................................................................

Card Holder Address ........................................................................................................................................................................

...................................................................................................................................... Postcode ............................................. Telephone Number ..................................................... Card Number (16 digit number) ....................................................................

(Switch/Solo) Issue No. ......... Expiry Date .................... Valid From .................... Security No. (3 digits on back of card) ......................

Cardholder’s Signature .................................................................................................. Date ....................................................

For Finance Use Only

Student Number Fee Payable £ Date

Name Course/Module Code Financial Arrangements Approved by:

SITS Course Code G/L Account Code Cost Centre/Internal Order Start Date

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application form cpd modules awarding level m credits · application form cpd modules awarding ......

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