Emergency Practitioner Minor Injury / Minor Illness Course

Application

Name of student: Employer (Manager):

NMC Pin NO:

Home Address: Employers Address:

Tel. no.: Tel. no.:

e-mail: e-mail:

Course: Cohort:

Module:

Academic Level:

(Please state whether diploma or degree level)

Name of Clinical Supervisor: Signature of Clinical Supervisor:

Clinical Supervisor’s Qualifications:

(I certify that I have the necessary prerequisites for the module/s shown Date:
above)
Student Signature:

(I certify that the Trust named above authorises payment for this Date:
programme of study)
Employer Signature:

Please return completed form to:

Penny Nevin
Course Co-ordinator
Emergency Department
Heart of England NHS Foundation Trust
Bordesley Green East
Birmingham B9 5SS

LB/SP/Application/April2007
Please read both sides of this application form before completing and signing.
 Instructions for Application Completion

Student NP Home Address:

This is required so that pre-course material may be sent directly to the
student.

Student e-mail address:

This can be either work or home but should be the one most accessed.

Course:
Please complete an application for either Minor Injury or Minor Illness, stating
which course on each application form if applying for both.

Cohort:
Please state month and year of intended course.

Module:
Applies to Minor Injury course; please state either; Adult Module or
Paediatric/X-ray Interpretation or both.

Academic Level:
Minor Illness – degree (level 6) only
Minor Injury – diploma (level 5) or degree (level 6)

Please state the level at which you are applying – to apply for degree level
you must have evidence of working at diploma level.

Clinical Supervisor:
Students should identify an appropriate clinical supervisor in their own
workplace prior to undertaking the course.

This person may be a Nurse Practitioner or Advance Health Care Practitioner

with training in the assessment and management of Minor Injury/Illness or
have been working in the Minor Injury/Illness setting for at least two years and
who has an NMC recognised mentorship qualification or someone with a
teaching qualification.

A General Practitioner (GP) working within a Minor Injury Unit or Primary Care
setting.
Medical Staff of Middle Grade or above within the Emergency Department.

Cancellations:
There will be nominal charge of £100 per student if places are cancelled
within 28 days of commencement of the course. This is to cover
administration which includes preparation of workbooks and texts which are
forwarded to students a month prior to the course.

Note: Application forms will not be accepted unless signed by all the relevant
parties.

LB/SP/Application/April2007
Please read both sides of this application form before completing and signing.