Mary-Ann Ingram - Oxford Brookes University

Clinical /Health Care PracticeProgramme AdministratorOxford Brookes UniversitySchool of Health and Social CareMRG48, Jack Straw’s LaneOxford OX3 0FLENGLANDTel: +44 (0)1865 488112Email: hcpshsc@brookes.ac.ukThank you for your enquiry regarding the above named programmes that are offeredat the School of Health and Social Care, Oxford Brookes University.To help you through the application process there is a checklist and FAQ sheet inthis pack, which highlights everything that you will need to return to us in order tohave your application processed and be considered for a place.Application formThe postgraduate application form is to be completed and signed then returned,ideally, with all supporting materials including references and funding statement tothe University’s Admissions Office. Please make sure that you have filled in allsections you need to complete prior to returning the application.FundingOn the Funding Statement, you will need to fill in the form and tick one of the optionsregarding funding. For all applicants who work within the South Central StrategicHealth Authority, funding must be agreed and signed off on the funding statement byone of the named education leads in your Trust.At http://www.brookes.ac.uk you will find further information about studying at OxfordBrookes University and the School of Health and Social Care. Programmes at theSchool are consistently given high ratings in Quality Assurance Agency reviews. Aswe receive a high volume of applications, we recommend that you read theinformation provided closely and act early in order to avoid disappointment.If you have any specific questions that are not covered in this application pack or onthe web, then please feel free to contact me via email hcpshsc@brookes.ac.uk,making it clear in the Subject heading that you are enquiring about the Clinical/HealthCare Practice programmes or modules therein, or by phone on 01865 488112. Myoffice hours are 8.30-16.00 Monday to Friday.We hope this programme meets your continuing professional development needsand we look forward to hearing from you and assisting you with the applicationprocess.Kind regardsMary-Ann Ingram

Checklist of Documents in this Mailing- Postgraduate Programme in Clinical/Health Care PracticeItemCovering LetterGeneral Course InformationFrequently Asked Questions (FAQ) documentApplication Form - including 2 reference forms, to be forwardedby the applicant to their refereesManager’s Protocol – to be forwarded by the applicant to theirManagerFunding StatementChecklist of Documents to Return with your ApplicationItemApplication FormManager’s ProtocolFunding Statement2 Reference Forms * to be returned by the refereesApplications cannot be considered until both references havebeen returnedEnglish Language Certificate (to be no more than 2 years old ifIELTS or TOEFL) if English is not your first language*Please Note: Applicants are responsible for ensuring that references are submitted to theUniversity. If you are not able to include the references in your return mailing, please ensure youconfirm with your referees that the reference forms are submitted in good time.

Health Care PracticeMSc/PGDip/PGCertApplication code HC88MSc (HC88A), PGDip (HC88B), PGCert (HC88C)Clinical Health Care PracticeMSc/PGDip/PGCertApplication code HC89MSc (HC89A), PGDip (HC89B), PGCert (HC89C)Course OverviewPreparing, Supporting and Developing Leaders of Health and Social Care withinClinical Practice, Education, Research and Management rolesIt is evident that continued developments in health and social care have resulted in the need forsome professionals to take greater responsibility, autonomy and accountability in developingservice provision, from both a strategic perspective and from a specific area of practice. Theimportance of ‘clinical’ leadership is paramount in achieving this aim. The course offersopportunities to a range of health and social care professionals (nurses, physiotherapists,radiographers etc.) in continuing professional and postgraduate academic development for nonmedicalhealth professionals. It aims to challenge and extend the knowledge, skills and attitudesof health and social care.A choice of pathways has been developed for you to consider according to your needs andcircumstances. Health Care Practice focuses on leadership, health care policy and practicedevelopment. Clinical Health Care Practice focuses primarily on the development of clinical skills,decision-making and role development in direct patient care.You will be given the option to study either one module (20 CATS M Level) or two modules at anyone time, working towards the completion of study at any of the three offered academic levels ofexit:• PGCert (3 Modules worth 60 CAT Credits)• PGDip (6 Modules worth 120 CAT Credits)• MSc (9 modules which includes a dissertation worth 180 CATS Credits).Depending upon the chosen pathway and intended exit award, you will study from thefollowing list of modules, in addition to optional modules from other courses:‣ Advancing Professional Practice‣ Advanced History Taking and Assessment‣ Diagnostic Reasoning in Practice‣ Non-Medical Prescribing (v300)‣ Leadership in Health and Social Care‣ Evidence-Based Practice‣ Advanced Research Design‣ Dissertation (MSc only)Promoting Excellence in Continuing Professional Development100312 - 2825

Our Approach to Teaching and LearningTeaching, learning and assessment approaches take full account of the wide range of personal andprofessional skills, experience and expertise held by each student, enabling you to learn from and withother health care professionals.You will be required to compile a portfolio as a means of promoting your learning, organising assessmentand enhancing your professional development. This portfolio is the vehicle for demonstrating evidence ofprogression and achievement in relation to the advancement of practice.Student Profiles“I work as Specialist Charge Nurse in the Emergency Department of Leicester RoyalInfirmary. I undertook the Clinical Health Care Practice Programme so that I coulddevelop my role in order to see and treat patients presenting to the Majors in theEmergency Department. The programme will facilitate and augment a systematicapproach to my existing nursing experience. The programme has been really good.It’s been very intense and really hard work, but it’s been an invaluable experience.”Matt Wensley“As a Lymphoedema Specialist for Myton Hamlet Hospice in Warwick, I feltthat the curriculum offered by the Health Care Practice programme fittedwell with my clinical job as well as supporting my vision for the developmentof my practice. The programme has met with my expectations andobjectives.I have really appreciated the differing learning and teaching styles of themodules I have undertaken. It has been an excellent experience.”Helen StanleyEntry Requirements‣ Applicants should be registered health care professionals, employed in health care in theUK and have a first degreeor‣ the equivalent in terms of prior learning at the appropriate level and have a minimum of threeyears' experience post-registration.Start DatesYou can either begin the course in Semester 1 or Semester 2. Module choices will be restricted bythe timetable conditions.Semester 1: September - December Semester 2: January – MayCourse FeesThe fees for the course are calculated on the number of modules taken:PG Cert: 3 modules PG Dip: 6 modules MSc: 9 modulesPlease contact the Programme Administrator for details of costs.Promoting Excellence in Continuing Professional Development100312 - 2825

Postgraduate Programme in Clinical/Health Care PracticeUK / EU FAQ SheetHow much does the course cost?Please contact the Programme Administrator.Is there any funding available?Yes. The John Henry Brookes Scholarship is available to a select number ofapplicants. The selection is made by key members of the School and one individualfrom another School/Department within the University. Information about this and anapplication form can be found at:http://www.brookes.ac.uk/schools/shsc/students/scholarships.htmlFor those working for the NHS in the following counties, tuition fee will be covered bythe South Central Strategic Health Authority Learning Beyond Registration Contract.However, this needs to be negotiated with your Line Manager and Trust EducationLead. Agreement needs to be confirmed before you can apply for the course.• Berkshire• Buckinghamshire• OxfordshireWe therefore advise those not to apply for the Scholarship.There are also other funding opportunities. Please refer to the University’s webpages relating to this, staff within the Student Support Office will be able to assist:http://www.brookes.ac.uk/studying/finance/support/pg_homeDirect telephone no.: +44 (0)1865 483172How regularly will I have to attend the University for Lectures?We recognise the fact that the majority of UK students are combining study withwork, and so we try, wherever possible, to have modules running on one day, in themorning and afternoon. Lectures for most modules run for a half-day.• Part-time students can expect to attend lectures once per-week.• Full-time students can expect to attend lectures two to three times per-week.Duration of Study• Part-time students are expected to complete their full Programme within amaximum of five years from their date of enrolment.• Full-time students are expected to complete their full Programme withineighteen months from their date of enrolment.

When do the Semesters run?The general rule is that Semester 1 runs for a twelve-week period from September toDecember and Semester 2 runs for a twelve-week period from late January to earlyMay. More detailed information can be found at:http://www.brookes.ac.uk/studying/teaching/calendarWhen completing the Postgraduate Application Form, do I need to indicatewhich career path I’m interested in?Yes, this would be helpful and can be highlighted in your Personal Statement.What should I write in my Personal Statement?The aim is to provide the Course Leader with information regarding your careerobjectives/plans and how your previous training and relevant work experience makesyou a suitable candidate, and what your future career aspirations are. Please writebetween 600 and 800 words.Will I be able to bring credits across from another Higher EducationInstitution?Yes, but this must be discussed on an individual basis with the Course Leader.How will I be assessed?The mode of assessment for the modules varies from discursive written assignmentsof 3,000 words or more, to examinations and group presentations. Furtherinformation is available from the Administrator and Course Leader.Where does the teaching take place?The majority of the teaching takes place at the School of Health and Social Care,Jack Straw’s Lane. Please go to the following link for the maps:http://www.brookes.ac.uk/schools/shsc/reachus.htmlParkingThere is no parking available either at the School, or on the Headington Campusbecause it’s situated in a residential area, and so we ask you to make use of theBrookes Bus, or the Park & Ride Facilities that are on offer:http://www.brookesbus.net/http://www.brookes.ac.uk/travel/buses/parkandrideAny other questions? You have the Administrator’s number on the cover letter,so give them a ring!

) Criminal ConvictionsTo help us reduce the risk of harm or injury to our students causedby the criminal behaviour of other students, we must know aboutany relevant criminal convictions you have.Relevant criminal convictions are only those convictions for offencesagainst the person, whether of a violent or sexual nature, andconvictions for offences involving unlawfully supplying controlled drugsor substances where the conviction concerns commercial drugdealing or trafficking. Convictions that are spent (as defined by theRehabilitation of Offenders Act 1974) are not considered to berelevant and you should not reveal them (but see the next paragraph).If you are applying for courses in teaching, health, social work andcourses involving work with children or vulnerable adults, you musttell us about any criminal convictions, including spent sentencesand cautions (including verbal cautions) and bindover orders. Forthese courses, you may need an ‘enhanced disclosure document’from the Criminal Records Bureau or the Scottish Criminal RecordOffice Disclosure Service. We will send you the appropriatedocuments to fill in.Courses in teaching, health, social work and courses involvingwork with children or vulnerable adultsFor these courses, you must tick the box if any of the followingstatements apply to you.a I have a criminal conviction.b I have a spent criminal conviction.c I have a caution (including a verbal caution).d I have a bindover order.e I am serving a prison sentence for a criminal conviction.If statement e applies to you, you must also give the prison addressas your postal address on page 1 of your application and a seniorprison officer must support your application.All other coursesFor these courses, you must tick the box if either of the followingstatements apply to you.a I have a relevant criminal conviction that is not spentb I am serving a prison sentence for a relevant criminal conviction.If statement b applies to you, you must also give the prison addressas your postal address on page 1 of your application and a seniorprison officer must support your application.Convictions that are spent (as defined by the Rehabilitation ofOffenders Act 1974) are not considered to be relevant and you shouldnot reveal them.If you enter a tick in the box you will not be automatically excludedfrom the application process. However, we may want to consideryour application further or ask for more information before making adecision.If you are convicted of a relevant criminal offence after you haveapplied, you must tell us. Do not send details of the offence, simplytell us that you have a relevant criminal conviction. We may ask youfor further information.You may find the following website useful: Criminal Records Bureauwww.crb.gov.uk8 Names and Addresses of TWO RefereesPlease fill in Section 1 on TWO copies of the PostgraduateReference Form and send these to the TWO people you havenamed on the application form. Both referees should be able tocomment on the quality and standard of your recent academic orprofessional work;The referees should send the completed forms directly to OxfordBrookes University.9 FinancePlease indicate how you intend to finance your postgraduate courseand living expenses, including any scholarships to which you haveapplied and the results, if known.10 DeclarationPlease read the declaration on the application form carefully. Youmust sign it or we cannot process your application. When yousign the form, you agree to follow these conditions:a) The information you have given is complete and accurate.b) You have the right to cancel, withdraw or suspend your applicationthrough us. You can do this by writing to us within 10 working daysof the date of our official offer letter to you.c) Your application will normally be confidential between:■ you, your referees and the appropriate staff at the university;■ your school, college or training organisation and your examboard or awarding body;■ your student support assessment body, and/or The StudentLoans Company, if relevant;■ in the case of international applicants, the British Council orappropriate agency.However, we try to detect and prevent fraud, and have the right togive outside organisations, including the police, the Home Office,local authorities, exam boards or awarding bodies and the BenefitsAgency, relevant information from your application form.d) If we believe that you or your referee have left out any information orgiven false or misleading information, we may take any necessarysteps to check whether it is accurate or complete.e) We may, at any time, ask you, your referee or your employer toprovide more information about your application (for example, proofof identity, status, qualifications or employment history).f) We may use information from your application form to collectstatistics. We will not tell any other organisation or publish anyinformation that could identify you.g) If you accept an offer of a place from the University, you must acceptthe terms and conditions in our prospectus (under ‘Conditions ofAcceptance’) or in the contract we sent you with or before the offerof a place. You must read these terms and conditions carefully.Please return your completed application and additional relevant documentation to the address given at the top of the application form.

Application noPostgraduate Application FormPlease return to:Read enclosed notes before filling in this form. Please write in BLOCK CAPITALS, using black ink.1 Programme DetailsAdmissions Office, Oxford Brookes University, Headington Campus, Oxford OX3 0BP UKIf you wish to receive confirmation of the arrival of your application form, please complete your name andaddress on the receipt acknowledgement slip provided with this form.Postgraduate Taught Course: Master’s Degree Postgraduate Diploma Postgraduate CertificateTitle of Course:Proposed start date (month-year): Mode of study: Full-time Part-timeDistance/open learning (where available)Give details of your preferred choice of options where appropriate2 Personal DetailsTitle (eg Mr/Ms/Miss/Mrs etc):Country of birth:Surname/Family name:Country of domicile/Area of permanent residence:First name(s):Previous surname, if changed:Male Female (tick one)Date of birth (day-month-year):Nationality:Applicants not born in the European Union please stateif appropriate,Day Month YearDate of first entry to the EU:Date of most recent entry to the EU:Date from which you have beengranted permanent residence in EU:Address for correspondence:Telephone number (include country and city code):Daytime:Evening (if different):Email:(please print clearly as email is our preferred method of communication)Fax number:Home/permanent address (if different from above):Telephone number (include country and city code):Daytime:Evening (if different):Fax number:Email:

3 Your Education (secondary and post-secondary) including professional qualifications and training coursesDates (from - to) Institution (include location) Subject(s) Result (eg BA Hons 2.1)month/year - month/yearContinue on a separate sheet, if necessary4 Your Employment / Professional Experience / Unpaid OccupationsDates (from - to)month/year - month/yearBrief details (eg job title, company name, main responsibilities)Continue on a separate sheet, if necessary5 Your English ProficiencyIf your first or main language is NOT English, the University requires evidence of your level of ability in spoken and written English. If you donot already hold a recent acceptable qualification in English (eg IELTS or TOEFL), you must either obtain one or successfully complete a UniversityPre-sessional course (UPS) before you can be admitted to a postgraduate course at the University.Please tell us about any English language qualifications which you hold and enclose copies of certificates with your application form.a) IELTS score (the normal minimum requirement is 6 or 6.5, depending on the programme. Test score: ........................Date of test:.......................Certificate no:....................b) TOEFL score: The normal minimum requirement is 550 or 575 (paper based),or 213 or 232 (computer based) depending on the programme. Test score: ........................Date of test:.......................Certificate no: ...................c) Any other English qualification which you hold, or are about to take: Test name: ................................................................................Test score: ................................. Date of test:.......................If you do not hold an acceptable English Language qualification you can apply to attend a University Pre-sessional course. If you would like to takethis course please tick here.Details of the course are available from www.brookes.ac.uk/go/ups, or email: icels@brookes.ac.ukor telephone +44 (0) 1865 483874.

6 Personal StatementThis is an important section and the admissions staff will pay particular attention to what you write here. You should explain why you are applyingfor this postgraduate programme, what you expect to achieve from it, and how it relates to your academic and career development.(See notes for guidance).

7 Disabilities or Special Needsa) Disabilities or Special NeedsIf you have a disability, special needs or a medical condition which might affect your studies please give details below, and indicate thedisability category in the box. (See notes 7a)Disability or Special Needs Details...................................................................................................................................................................................................................................................................................................................................................................................b) Criminal ConvictionsIf you have a relevant criminal conviction, tick the box.Please see notes for guidance for a definition of relevant criminal convictions.8 Names and Addresses of TWO Referees (You must send enclosed reference forms to referees named below)(i) Name:Address:(ii) Name:Address:Tel:Fax:Email:Tel:Fax:Email:9 Finance9a UK/EU students only: 9b International students only:How do you expect to pay your tuition fees?How do you expect to pay your tuition fees?Research Council Sponsored by Employer Government grant Sponsored by Employergrant/studentshipYourself Other Yourself Other9cAll students: If you hope to obtain a grant or sponsorship, or funding from other sources,please give details (eg name of funding body/sponsor):10 DeclarationI confirm that the information on this form is complete and accurate and that no information requested or other material information has beenomitted. I give my consent to the processing of my data by Oxford Brookes University. I have read the Notes for Guidance and I undertake to bebound by the conditions set out therein.Signature: ................................................................................................................... Date: .............................................................................Office Use OnlyUnconditional Offer (date) .......................................................................................Agent Code/Stamp:Conditional Offer (date) ..........................................................................................Condition ...............................................................................................................Reject (date) ...........................................................................................................Reason ...................................................................................................................CSMS Course Code:Fair/Event Code:

Application noPostgraduate Reference FormPlease return to:Admissions Office, Oxford Brookes University, Headington Campus, Oxford OX3 0BP UKSection 1. To be completed by the applicant:Full name of applicant:Postgraduate taught courses: Master’s Degree Postgraduate Diploma Postgraduate CertificateTitle of course:Mode of study: Full-time Part-time Distance/open learning (where available)Section 2. To be completed by the referee:Note to referee: your honest and forthright assessment of the above named applicant is a necessary part of the application process to postgraduateprogrammes at Oxford Brookes University. When writing personal comments about an applicant, please remember that, underthe UK’s Data Protection Act, the applicant can ask for a copy of the reference and any other personal information that the University holdsabout them.We realise providing a reference requires time and effort and we greatly appreciate your assistance. Please print or type your response, and whencomplete, please return it to the address stated at the top of this form. If you have any questions, please contact the Postgraduate Taught CoursesAdministrator on pgt-admin@brookes.ac.uk or telephone +44 (0)1865 483713.How long and under what circumstances have you known the applicant?What do you consider to be the applicant’s strengths?What do you consider to be the applicant’s weaknesses?Continued over page...

Using the chart below, please rate the applicant relative to other students or employees whom you have known in a similar capacity.Please indicate the group with whom you are comparing the applicant (eg students, co-workers, etc): .................................................Outstanding(Top 5%)Excellent(6-20 %)Good(21-30 %)Average(31-40 %)BelowaverageUnableto rankAcademic potentialAbility to work with othersAbility to work independentlyInitiativeMaturityMotivationWritten communication skillsOral communications skillsCommitmentCreativityAnalytical skillsPlease comment on your rankings indicated above, making any additional statements concerning the applicant’s academic development to date andpresent performance; expected examination results/qualification (if appropriate); interpersonal skills; and if the applicant is from overseas, indicateyour understanding of their ability to study at postgraduate level in English.Please continue on a separate sheet, if necessaryReferee’s Name:Position/Title:Referee’s Signature:Date:Organisation:Address:City/Town:Postal Code:Telephone No:Country:Email:Fax No.

Application noPostgraduate Reference FormPlease return to:Admissions Office, Oxford Brookes University, Headington Campus, Oxford OX3 0BP UKSection 1. To be completed by the applicant:Full name of applicant:Postgraduate taught courses: Master’s Degree Postgraduate Diploma Postgraduate CertificateTitle of course:Mode of study: Full-time Part-time Distance/open learning (where available)Section 2. To be completed by the referee:Note to referee: your honest and forthright assessment of the above named applicant is a necessary part of the application process to postgraduateprogrammes at Oxford Brookes University. When writing personal comments about an applicant, please remember that, underthe UK’s Data Protection Act, the applicant can ask for a copy of the reference and any other personal information that the University holdsabout them.We realise providing a reference requires time and effort and we greatly appreciate your assistance. Please print or type your response, and whencomplete, please return it to the address stated at the top of this form. If you have any questions, please contact the Postgraduate Taught CoursesAdministrator on pgt-admin@brookes.ac.uk or telephone +44 (0)1865 483713.How long and under what circumstances have you known the applicant?What do you consider to be the applicant’s strengths?What do you consider to be the applicant’s weaknesses?Continued over page...

Using the chart below, please rate the applicant relative to other students or employees whom you have known in a similar capacity.Please indicate the group with whom you are comparing the applicant (eg students, co-workers, etc): .................................................Outstanding(Top 5%)Excellent(6-20 %)Good(21-30 %)Average(31-40 %)BelowaverageUnableto rankAcademic potentialAbility to work with othersAbility to work independentlyInitiativeMaturityMotivationWritten communication skillsOral communications skillsCommitmentCreativityAnalytical skillsPlease comment on your rankings indicated above, making any additional statements concerning the applicant’s academic development to date andpresent performance; expected examination results/qualification (if appropriate); interpersonal skills; and if the applicant is from overseas, indicateyour understanding of their ability to study at postgraduate level in English.Please continue on a separate sheet, if necessaryReferee’s Name:Position/Title:Referee’s Signature:Date:Organisation:Address:City/Town:Postal Code:Telephone No:Country:Email:Fax No.

Application noEthnic Origin FormPlease state your ethnic origin in the box using the codes provided. However, this sectionshould be completed only by applicants whose area of permanent residence (see section 2of the application form) is in the UK.WhiteWhite 11BlackBlack Caribbean 21Black African 22Other black background 29AsianIndian 31Pakistani 32Bangladesh 33Chinese 34Other Asian background 39MixedWhite and Black Caribbean 41White and Black African 42White and Asian 43Other mixed background 49Other ethnic backgroundOther ethnic background 80Please return this form with your completed application.This information WILL NOT be made available to Admissions Tutors for selection purposes

Please fill in your name and address in the box below.Application noThank you for applying to study on our postgraduate programme at OxfordBrookes University. Your application has been forwarded to the relevant courseteam and a decision will be taken as soon as possible.If you have any queries regarding the progress of your application, please contactthe Admissions Office, email admissions@brookes.ac.uk, quoting your applicationnumber above.www.brookes.ac.uk/postgraduate

School of Health and Social CarePostgraduate Programme in Clinical Health Care PracticeProtocol for ManagersThis form must be signed by the applicant’s manager and returned to the ProgrammeAdministrator, at the address shown below.Please note that students undertaking this programme will need the time to attendtaught sessions, and for private study in order to be successful and derive benefit fromthe course. This will be a minimum of one day per week.For information, you may find it useful to know that in previous years studentevaluations have shown that those with support for study leave, in addition to thetaught sessions, have felt they have benefited significantly from the programme in theirprofessional development. We would request that you take this into considerationwhen allocating study leave for this applicant.. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . has applied for aplace on the above programme. I understand that s/he will require study leave and the support of anamed professional mentor. Students undertaking the Advanced History Taking and Assessment andNon-Medical Prescribing modules will additionally require the support of a clinical supervisor (usually amedical practitioner at specialist registrar level or above).Manager’s agreement to support this candidate’s application for the programme.Thank you for agreeing to provide support to the above student undertaking a postgraduate programme atOxford Brookes University. Would you please confirm that the learning opportunities relevant to the learningoutcomes/ competencies for the programmes that the student is undertaking are available in the workplacearea or through negotiated visits in local placement areas.MANAGER’ SIGNATURE: . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .MANAGER’S NAME: . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .JOB TITLE: . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .ORGANISATION: . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Manager’s e-mail: . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Manager’s telephone number: . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .DATE: . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Please return this form to: Administrator for Clinical Health Care Practice, School of Health and SocialCare, Oxford Brookes University, Jack Straw’s Lane, Marston Road, Oxford OX3 0FL

Name:UK FUNDING STATEMENT TO BE RETURNED WITH THE APPLICATION FORM(please complete ALL sections)Practice area (eg cardiology/GP surgery/community):Your name must appear here identically to how it doeson your health care registration, including middle namesif you have used them.Hospital/Institution (eg John Radcliffe Hospital):Professional body registration number:e.g. NMC PIN, HCP registrationCertificates of attainment cannot be given unless wehave your registration number from your professionalgoverning body.Title of course AND tick relevant box below for level of study: …………………………………………….Associate - number of modules to be taken …… or full short courseDip HE BA BSc BA Hons BSc Hons PG Cert PG Dip MScCourse commencement date: …………………… Intended completion date: ……………………Trust Education Lead’s Signature…………………………………………….. Date……………………Trust Education Lead’s Name (please print)………………………………………………………………Payment, please pick ONE of the following:1. I work within South Central SHA in one of the following Trusts (please tick):Trust Tick Trust TickEast Berkshire Primary Care TrustsOxfordshire & Buckinghamshire Mental Health TrustWest Berkshire Primary Care TrustsHeatherwood and Wexham Park NHS TrustCommunity Health BuckinghamshireMilton Keynes General Hospital NHS TrustMilton Keynes Primary Care TrustsNuffield Orthopaedic Centre NHS TrustOxfordshire Primary Care TrustsOxford Radcliffe Hospitals NHS TrustRidgeway Partnership NHS Trust(Learning Disability)Royal Berkshire NHS Foundation TrustBerkshire Healthcare NHS Trust (MentalHealth)South Central Ambulance Service NHS TrustBuckinghamshire Hospitals NHS TrustSouth Central Strategic Health Authority/NESCOR I work within South West SHA in one of the following Trusts (please tick):Trust Tick Trust TickWiltshire PCTGreat Western Hospitals NHS Foundation TrustSwindon PCTGreat Western Ambulance TrustI work for the Trust indicated above but I am being funded by the South West SHA through the StrategicServices Improvement Fund (SSIF)OR2. My employer is from out side the above trusts and has agreed to pay my fees.They will supply me with a letter of support with invoice details when I enrol.3. I will be funding myself and will bring payment with me when I enrol. Office use ONLYUniversity course code:Number of modules in current academic year:Number of modules in total:

South Central SHA Trust Education LeadsNHS Trust Requiring Sign OffBuckinghamshire Hospital NHS TrustCommunity Health Buckinghamshire(previously named Buckinghamshire PCT)Berkshire Healthcare Foundation Trust(mental health)Royal Berkshire NHS Foundation TrustBerkshire East PCTHeatherwood and Wexham Park HospitalsNHS Foundation TrustNuffield Orthopaedic Centre NHS TrustOxfordshire PCTMilton Keynes PCTOxford Radcliffe Hospital Trust – everythingbut mentorship moduleOxfordshire Radcliffe Hospital Trust –mentorship onlyBerkshire West PCTRidgeway Partnership – OxfordshireLearning Disability NHS TrustMilton Keynes HospitalSouth Central Ambulance TrustOxfordshire and Buckinghamshire MentalHealth Trust – everything but mentorshipOxfordshire and Buckinghamshire MentalHealth Trust – mentorship onlySouthampton Hospital TrustTrust Education staff who can signoff applicationsCelina Eves, Fiona Goodwin, SarahWatson-FisherWendy Lee, Rachael CorserDi Foxwell, Julie BennettsJoan Potterton, Jo SandySuzanne Awadallah, Iris MitchellClare Culpin, Jane Campbell, DeirdreThompsonRachel Mellor, Ian MacKenzieSue Byrne, Clair PriceXanthe Cummings (Non MedicalPrescribing only)Alison DrageJohn CampbellHelen Hastings, Margo Boore, BridgetBrogden, Naomi-Clements.ColeGlenis Henry, Debbie Browne, SarahManningNeil Brown, Natalie Smith, Dave GossJulie Willison, Joanna Matthews, RobStaceyIan Teague, Christina FowlerRhonda Riachi, David SlingoSandra Williamson, Clare IresonAlison TrenerryFor South West SHA Trust authorized signatories please check with yourindividual Trust.