Application form - Masters by 13MK5XQm

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									                         MASTERS LEVEL
               APPLICATION FORM


      RECOGNITION AND MANAGEMENT OF THE
        ACUTELY UNWELL ADULT MODULE (RAM)
                                         (incorporating the IMPACT Course)




                                                                                
        I wish to apply to undertake the RAM module as a stand alone                         Please complete all sections
        module at Masters level (SCQF level 11)


                                                                                
        I am already on the MSc Advanced Practice Programme and                                   Please complete
        wish to apply for the RAM module                                                     Supplementary Sheet 2 only


                                                                                
        I would like to apply for the RAM module and the MSc                                 Please complete all sections
        Advanced Practice programme




Applicants should complete the attached standard university application form and supplementary sheets for
                this specific course. Completed applications and a current CV should be sent to:
 Irene Fulton, Practice Development, 3rd Floor Walton Building, Glasgow Royal Infirmary, 84 Castle Street, Glasgow, G4 0SF
                                                                                                                               Admission Number


                       APPLICATION FOR
                       A PROGRAMME IN POST GRADUATE STUDY


TO THE APPLICANT

1.   Please complete the form in black ink in BLOCK CAPITALS

2.   Surname or family name. Please give the name you wish for correspondence and by which you wish to be known should you
     register at the university.

3.   If you are recognised by the UK authorities as an immigrant, a settled person, or a refugee, and have lived in the UK since being
     recognised please enclose a copy of the letter from the Home Office recognising you as a person in one of these categories.

4.   Programmes normally commence in January. There is no formal closing date for applications, but early application is advised
     (preferably by 31st May, see current University Prospectus for exceptions). Applicants should note that many departments will
     wish to see as many applications for a course as possible before making a decision, and a speedy response to application is not
     always possible.

5.   Completed application forms should be returned to: Irene Fulton, Practice Development, 3rd Floor, Walton Building, Glasgow
     Royal Infirmary, 84 Castle Street, Glasgow. G4 0SF

6.   To enable your application to be considered, personal data provided on your application will be entered onto the University's
     computer records. At all times use of this data will be strictly in accordance with the principles laid down by the Data Protection
     Act 1998.

NAME AND ADDRESS
SURNAME/FAMILY NAME                                                   PERSONAL DETAILS                Male – M
FORENAMES                                                                                             Female - F
TITLE(Mr/Mrs/Miss/Ms)
CORRESPONDENCE ADDRESS                                                Date of Birth (Day/Month/Year)
                                                                             Years             Months
                                                                                               Your age on 30 September in year of entry to course
                                                                      Country of Birth
                                                                      Nationality
Postcode                                                              How long have you been a resident in the UK
Telephone Number                                                      (insert life if appropriate)                              Years
PERMANENT HOME ADDRESS



Postcode                                                              Telephone No.
Email Address
PROGRAMME DETAILS
Title of Programme     MSc Advanced Nursing
Application for entry in the academic year 20
FOR OFFICIAL USE ONLY
DECISION:              Interview
                                Yes             No                     UOF                           COF                          REJ
PROFICIENCY IN ENGLISH
Is English your first language              Yes                     No
If English is not your first language give details of English language qualifications held and attach copies of certificate. If you do not
hold a recent acceptable qualification in English, you will be required to obtain one as a condition of offer.
ACADEMIC QUALIFICATIONS – SCE/GCE other School Qualifications and FE Qualifications
Subject and Level      Examining Body                                          Exam Date             Results        Grades or Bands




HIGHER EDUCATION: PROGRAMME CONTENT
Please give details of any programme undertaken in Higher Education including those where no award was achieved.
University/College                 Programme/Content/Subject/Grades                    From                                   To
                                                                                      Month          Year          Month           Year




PROJECT WORK


Have you carried out an extended piece of work, project or dissertation, resulting in:        A written report          Yes            No


                                                                                         An oral presentation           Yes            No
If YES please give the title:
PROFESSIONAL AND OTHER QUALIFICATIONS
Name of Awarding Institution/Body                 Subject(s) in which award obtained             Qualification obtained
                                                                                                 (give details and whether obtained by examination/exemption)




ADDITIONAL INFORMATION
Give any other information you wish in support of your application, including information offered in lieu of formal academic qualifications eg
relevant experience for mature students. Include a list of your publications (if applicable). Continue on a separate sheet if necessary




Where did you hear about the programme applied for?
                                                                                  Newspaper                   Further Education College
                                                                                  Open Day                              Other: Please state
SOURCE OF FINANCE
Please state how you intend to finance your proposed study. Give details of any application(s) for grant/scholarship/sponsorship that
you have made. If a grant/scholarship/sponsorship has already been awarded, please attach a copy of your award letter.




PLEASE NOTE: COMPLETION OF THIS SECTION DOES NOT CONSTITUTE AN APPLICATION FOR FINANCIAL SUPPORT
Do you have any criminal convictions?                                          YES                           NO
REFEREES
REFERENCES MUST ACCOMPANY THIS APPLICATION FORM
Give names, position and address of two people who have been involved in supervising your recent academic work. If you have not
been in education for a number of years please give your current employer instead of academic referee.
Name                                                               Name
Position                                                                    Position
Address                                                                     Address



Telephone                                                                   Telephone
Fax                                                                         Fax
RESIDENCE
Where is your permanent home?(Please tick appropriate)                                             UK         EEC         Other
How long have you been resident in the UK? Insert ‘Life’ if appropriate
Date of first entry to the UK/Month/Year
Give details of periods resident outwith UK               Month                Year
EMPLOYMENT AND EXPERIENCE
Give details of your work experience (if any) and of any previous employment, including name and address of employer(s), position
held, type of work undertaken and duties. Continue on a separate sheet if necessary.




SPECIAL NEEDS
Please tick box if you have any special needs so that we can contact you for interview to discuss them
DECLARATION
I certify that the answers and other information given in this application are correct and complete. If I am
admitted to the course I undertake to observe the University regulations and to ensure payment of fees and other
liabilities.
Signature                                                     Date
                                 STATEMENT BY REFEREE

                      In accordance with the Data Protection Act 1998, information provided by referees will be made               available to
                      applicants on their request.

Notes of Guidance for Educational Referees
The Referee report is an important part of the selection process and the information you give will aid admission tutors in making their
decisions. Your report will be treated in the strictest confidence. Your reference should cover the following points.
    1.     Suitability for the course(s) applied for
    2.     Previous and potential academic performance
    3.     Career aspirations
    4.     Any other personal circumstances relevant to the application
NAME OF REFEREE
POST / OCCUPATION / RELATIONSHIP
ADDRESS


                                                                           TELEPHONE NUMBER

Please return the completed statement to:
           Irene Fulton, Practice Development, 3rd Floor Walton Building, Glasgow Royal Infirmary, 84 Castle Street, Glasgow, G4 0SF

NAME OF APPLICANT (Block Capitals)
PROGRAMME(s)




                                                                                  SIGNED:
                                                                                  DATE:
                                                                                                             Admission Number
                                                       SUPPLEMENTARY SHEET 2
                                                   Recognition and Management of the Acutely
                                                                 Unwell Adult
                                                                  MMB712878


                                                       School of Health
             Recognition and Management of the Acutely Unwell Adult Module
Personal Details
Surname / Family Name                 See page 2

Forenames                             See page 2

Title (Mr/Mrs/Miss/Ms)                See page 2                    Date of Birth (Day/Month/Year)   See page 2

UKCC / NMC PIN number


Job Title:
Workplace Address:


Do you work on or contribute to a Hospital at Night team?           YES              NO

If you do not work on a Hospital at Night team, please explain your role




Individual staff prerequisites (please circle yes or
no)
6 years post registration                YES             NO         Venepuncture                      YES           NO
ALS qualification                         YES            NO         Cannulation                       YES           NO
                        Date achieved
Nurse prescribing (preferred)             YES            NO
Basic undergraduate degree and / or evidence of recent successful study       YES              NO
(please enclose a copy of certificates)
Clinical assessment skills                YES            NO
What course did you undertake:
Clinical Assessment for Nurse Practitioners NCHCN354 at GCU

Advanced Clinical Examination NUR96 at Stirling University

5-day Patient Assessment Workshop, PDUK

3-day Clinical Hx taking and Physical Examination, M&K Update

RCN approved Nurse Practitioner degree programme

Other training
please describe below (title of course, provider and length of
course)
Availability of support / mentoring                        YES         NO
(Please give brief outline)




Details of Designated Mentor / Supervisor
Name:
Profession / Designation / Qualifications:
Workplace address:




Contact telephone number:

Availability of appropriate post for the individual to return to, to practice and sustain their new skills

    YES             NO        (please give brief detail)




Any additional information in support of this application?
(to be completed by Hospital at Night Lead, Advanced Practice Lead, Associate Director of Nursing or Director of Nursing)




Brief statement in support of application (to be completed by the candidate.
Continue on separate sheet if necessary)




I nominate the above candidate and guarantee that if successful the candidate will be supported by the service to undertake
this course and that there will be a suitable post for him / her to return to in order to practice his / her newly acquired skills.


Signature of Hospital at Night Lead, Advanced Practice Lead or Nurse Director




A Curriculum Vitae should be submitted with this application
Applicant’s curriculum vitae enclosed                      YES           NO
Rehabilitation of Offenders’ Act 1974 (Exceptions) Order 1975

Do you have any criminal convictions?                               YES             NO

Details of any convictions must be given. Because of the nature of the work for which you are applying, this post is excepted from
The provisions of Section 4(2) of the Rehabilitation of Offenders’ Act 1974 by virtue of the Rehabilitation of Offenders’ Act 1974
(Exceptions) Order 1975. Applicants are, therefore, not entitled to withhold information about convictions which for other purposes
are ‘spent’ under the provisions of the Act, and in the event of employment, any failure to disclose such convictions could result in
dismissal or disciplinary action. Any information given will be completely confidential and will be considered only in relation to an
application for positions to which the order applies. Please attach details on a separate sheet.


WORKPLACE SUPPORT

If you choose to undertake any practice-based modules, this may have implications for your workplace. This may include
the appointment of a mentor and the achievement of clinical competencies. Please discuss this with your line manager or
supervisor and obtain their support for this.

This has been discussed with me and I agree to support the applicant.

Name: (please print)

Signature:

Ward / Clinical Area / Hospital:

Position:

Date:
ETHNIC ORIGIN (To be retained in the Admissions Office)


PERSONAL DETAILS


Surname / Family Name
Forenames                                                                                                    Admissions number
Title (Mr/Mrs/Miss/Ms)


Date of Birth (Day/Month/Year)



ETHNIC ORIGIN OF APPLICANT
The following question is to enable the University to monitor its Equal Opportunities policy.

Please circle the appropriate number

      10     White                                           33       Asian or Asian British - Bangladeshi

      11     White – British                                 34       Chinese

      12     White – Irish                                   39       Other Asian background

      13     White Scottish                                  41       Mixed – White and Black Caribbean

      14     Irish Traveller                                 42       Mixed – White and Black African

      19     Other White background                          43       Mixed – White and Asian

      21     Black or Black British – Caribbean              49       Other Mixed background

      22     Black or British – African                      80       Other Ethnic background

      29     Other Black background                          90       Not Known

      31     Asian or Asian British – Indian                 98       Information refused

      32     Asian or Asian British – Pakistani

								
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