School of Community and Health Sciences

PROGRAMMES APPLICATION FORM Specialist Community Public Health Nurse (Health Visitor or School Nursing) / Primary Care (District Nursing) Before completing this form, please read these notes carefully and use them as a guide to complete your application and for future reference. This form cannot be used to apply for other courses. If you would like to apply for a different course please see our website at http://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. APPLICATION PROCESS Processing Your Application If you have any queries regarding the Programmes, please refer to http://www.city.ac.uk/scn or email the Programme Director, Rita Newland, at [email protected] including your contact details. If you have any queries regarding completion of the application form, please contact the course administrator, Barbara Kirk, Tel: 020 7040 5782 or email: [email protected] Please send your application form to: CPD Programme Administration Team City University London Philpot Street Whitechapel London E1 2EA Alternatively you can fax your completed application, marking it for the attention of CPD Programme Administration Team: Fax: +44 (0)20 7040 5811 If faxed – please ensure you subsequently post the hardcopy of the application form to the address above. 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 via telephone on 020 7040 5828
We will send confirmation on receipt of your application, in writing, to your correspondence address.
We will be sending you regular information, before, during and after you have commenced your Programme therefore; if any of your details or circumstances change you must inform us as soon as possible, in writing at the above address or via [email protected]
Please note: you are advised to keep a copy of your completed application for your records.

School of Community and Health Sciences

Specialist Community Public Health Nurse (Health Visitor/School Nurse) / Primary Care (District Nurse) Please complete this form using BLACK INK, write neatly and clearly in order for us to process it promptly. All sections must be completed. Please refer to the guidance notes before completing this application.

PROGRAMME INFORMATION Please select either full time (1 year duration) or part time (2 years duration). If you attained a grade of 2.1 for your degree you can apply to study for MSc/PG Diploma awards. If you attained a grade of 2 or below you can apply to study for a BSc (Hons) award. Code Programme Route Please Start Date Mode of Attendance Tick Please delete as Please delete as appropriate appropriate BSc (Hons) Specialist Community Public Health USSCHV September 2010 Full Time / Part Time Nurse (Health Visitor) BSc (Hons) Specialist Community Public Health Full Time / Part Time USSCSN September 2010 Nurse (School Nursing) USPCDI

BSc (Hons) Primary Care (District Nursing) MSc/PG Dip Specialist Community Public Health Nurse (Health Visitor) MSc/PG Dip Specialist Community Public Health Nurse (School Nursing)

PSPSHV PSPSSN PSPCDN

MSc/PG Dip Primary Care (District Nursing)

September 2010

Full Time / Part Time

September 2010

Full Time / Part Time

September 2010

Full Time / Part Time

September 2010

Full Time / Part Time

PERSONAL INFORMATION Have you studied at City University London in the past? Yes Title

If ‘Yes’ Please state your student number (if known)

No First Name

Surname

Known as Name (if applicable)

Date of Birth

Gender (please tick)

Mr/Miss/Mrs/Ms/Dr/Other ……………...

Previous Name(s) (if changed)

D D / M M / Y Y Y Y

M

F

Permanent Address ……………………………………….…………………………………….

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

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Postcode……………………………………………………….…………

Postcode…………………………………………………………………

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

Nationality (as on passport - please state dual nationality)

Tel No. (Work) ..……………………………………………EXT:…………

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

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

Personal

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

Email Address

s

If 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) .……………………….………………………………………………………

School of Community and Health Sciences

Next of Kin (Name)

Next of Kin (Relationship)

NMC Pin

Next of Kin (Contact Number)

Work Status

NMC Pin Expiry Date D D / M M / Y Y Y Y

Full Time

How many days absence from work have you had due to illness in the past 2 years?

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Part Time

Please State your current Nursing Grade and Salary Point

Band (AFC) Grade ___________

Days

Salary Point ___________

MARKETING MONITORING How did you hear about the programme? City University Website

Other Website

Advertisement

Letter

Email

Previous/Existing Student

Referral

Prospectus

Event

Other

PRESENT OR MOST RECENT EMPLOYMENT 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 NHS Trust employing you (Please state the name of the NHS Trust you work for)

Name of Employer (the name of the hospital, practice or agency you work for)

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

School of Community and Health Sciences

EMPLOYMENT HISTORY Please list all your previous posts/work experience, paid or unpaid, full or part time, over the last 5 years. Indicate if you obtained any post through an agency (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

PARENTAL EDUCATION (BSc (Hons) applicants only to complete this question) The following question is about your parents’ level of education. This includes parents, adoptive parents, step-parents or guardians who have brought you up. We are required by the Higher Educational Statistics Agency (HESA) to request this information from students studying at undergraduate level, i.e. level 3 or below. If you intend to study for the MSc/PG Dip award you do NOT need to complete this question. Do any of your parents (as defined above) have any higher education qualifications, such as a degree, diploma or certificate of higher education? Yes

No

Don’t know

Information Refused

ENGLISH LANGUAGE QUALIFICATIONS (to be completed by applicants if English is NOT your first language) If English is not your first language, you must provide show evidence that your command of the English language is suitable for entry to degreelevel studies. A pass in one of the following qualification is the minimum expectation of City University London:
IELTS Test of the British Council at 7.5.
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

School of Community and Health Sciences

ACADEMIC QUALIFICATIONS, PROFESSIONAL QUALIFICATIONS AND EDUCATION Start with the most recent and give your Academic and Professional qualifications and education. List all the courses you have attended after secondary school. Include courses undertaken whilst you were working. These can include degree, diploma, modules, study days, short courses etc. Education Establishment(s) Attended

Subject

Academic Level and/or Award

Grade or Academic Credits

Duration of Course

Date Completed

School of Community and Health Sciences

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

School of Community and Health Sciences

DECLARATION OF A CRIMINAL RECORD This post is subject to the Rehabilitation of Offenders Act (Exceptions Order) 1975 and as such it will be necessary for a submission for disclosure to be made to the Criminal Records Bureau to check for any previous criminal convictions. If you are offered a place, your commencement of the programme will be subject to completion of a satisfactory Criminal Records Bureau check undertaken by your employing Trust. For more information visit the CRB website www.crb.gov.uk, or read the policy guidance information published by the Department of Health www.doh.gov.uk/crb/policechecks.pdf

PCT SELECTION Please indicate your first and second preference for PCT by placing a 1st and 2nd choice in the boxes respective boxes City & Hackney Primary Care Trust Enfield Primary Care Trust Newham Primary Care Trust Tower Hamlets Primary Care Trust Other PCT (Not listed – please complete section 9b below)

ALTERNATIVE PCT SELECTION If you are obtaining sponsorship through another PCT that is not listed, you must have this section stamped by your chosen PCT representative granting authorisation. This is the person who is in charge of the contract between your chosen PCT and City University London.

PCT Name ……………………………………………………………………

PCT Lead’s Name…………………………………………………………..

PCT Address…………………………………………………………………

Tel No. ………….. …………………………………………………………

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Email Address

s

………………………………………………………………………………… Postcode…………………………………………………………………….. Authorised Stamp

Date D D / M M / Y Y Y Y

School of Community and Health Sciences

REFERENCES Please provide the name and contact details of at least 2 referees. We will ask them to provide a reference for you if you are offered a place on the course. We cannot accept references from relatives or friends. 1. Work Reference: Your first referee must be from your current or last employer (e.g. Line Manager). 2. Second Referee: This must be from a previous employer (e.g. Line Manager) or work colleague. 1. Work Reference Name Relationship

Address

Tel

Fax

Email

2. Second Referee Name

Relationship

Address

Tel

Fax

Email

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.html

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 If you leave employment with your sponsoring Trust 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 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 programme. Please note we do not accept telephone cancellations. The School reserves the right to charge a cancellation fee of £150. If you do not attend the course 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 applicant) I confirm that I have read and understood and agree to the Ordinances and Regulations of City University London and the Financial Terms & 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 (dd/mm/yyyy)

D D / M M / Y Y Y Y

School of Community and Health Sciences

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 http://www.city.ac.uk/hr/policies/equality_diversity.html

Please indicate with a tick where appropriate In order for us to assist in our Equal Opportunities monitoring please tick one of the Ethnic Origin following boxes, which best describes your ethnic Origin. 10- White

34- Chinese

14- Irish Traveller

39- Asian Other background

21- Black or Black British Caribbean

41- Mixed White and Black Caribbean

21- Black or Black British Caribbean

42- Mixed White and Black African

22- Black or Black British African

43- Mixed White and Asian

29- Black Other background

49- Other Mixed Background

31- Asian or Asian British Indian

80- Other Mixed Background

32- Asian or Asian British Pakistani

90- Not Known

33- Asian or Asian British Bangladeshi

98- 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 (Contact the Disability Officer to discuss). 4. Do you have a disability? Tick one of the following boxes if you wish to declare a disability or long term medical condition.

YES

NO

01 Dyslexia or other specific learning difficulty

06 Mental health difficulty

02 Blind/partially sighted

07 Unseen disability e.g. diabetes or epilepsy

03 Deaf/hearing impairment 04 Wheelchair user/mobility difficulties 05 Personal care support

08 Multiple disabilities 09 Other disability 10 Autistic Spectrum Disorder

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