School of Health and Social Care
Module Application Form

HS955 Consultation & Assessment

All sections of this form to be typed. Signatures to be ‘wet’ signatures or ‘electronic’ signatures. Typed names cannot be accepted in place of a wet or electronic signature.

Start Date:	Click or tap here to enter start date
Please indicate level of study:	Select level of study (Level 7 or level 6)

Personal Details

Title:	Select title
Surname:	Click or tap here to enter surname
First Name:	Click or tap here to enter first name
Previous Surname: (if applicable)	Click or tap here to enter previous surname
Date of Birth:	Click or tap to enter a date.
Country of Birth:	Click or tap here to enter country of birth
Nationality: (as shown on birth certificate)	Click or tap here to enter nationality
Home Address: (including postcode)	Click or tap here to enter home address including postcode
Contact Number:	Click or tap here to enter contact number
Email Address: (course information will be sent to the email address provided)	Click or tap here to enter email address

Clinical Profession:	select profession (Allied Health Professional, Healthcare Scientist, Midwife, Nursing, Other)

If profession indicated as Allied Health Profession, please specify role:	Click or tap here to specify role

If profession selected as ‘Other’ please specify role:	Click or tap here to specify role

Professional Body:	Choose professional body (NMC, HCPC, GPhC or Other).
Please provide registration Pin:	Click or tap here to enter registration pin.

Academic & Professional Qualifications

Date of Award	College / University	Course Title / Subject	Qualification / Grade

Employment History (including current role to be listed first – maximum 5 years)

Date From	Date To	Place of Employment	Job Title

Funding:	Click here to select funding stream (Apprenticeship, Employer Funded, Fee Waiver, NHS England, Other or Self-Funding

Where funding indicated as ‘Other’ please specify:	Click or tap here to specify funding

Self-funded applicants pay the full course fee online prior to registering onto the course. A link will be provided when your place is confirmed, allowing you to pay the course fee prior to registration. Payment can be made by credit card, debit card or bank transfer. Please note the University does not offer payment terms via instalments.

Current Employer Details (Place of work)

Current Employer Name:	Click or tap here to enter employer name
Employer Address:	Click or tap here to employer address
Employer Postcode:	Click or tap here to employer postcode

Employer Funded Invoice Details – to be provided by person / team authorising the funding. PO/Ref can be applicants name if employer does not have a purchase order system in place.

Employer invoice address & postcode:	Click or tap here to enter employer invoice address & postcode
Employer Invoice email address:	Click or tap here to enter invoice email address
Purchase order number / reference (if known):	Click or tap here to enter PO or reference

Employer Funding Authorisation – to be completed by person / team authorising the funding.

In signing you are confirming the funding for the course fee has been approved.

Name of authorising member of staff:	Click or tap here to enter name
Email address:	Click or tap here to enter email address.
Contact number:	Click or tap here to enter contact number
Signature: Please sign - wet or electronic signatures are accepted, we cannot accept typed names.
Date signed:	Click or tap to enter date signed.

Employer / Line Manager sign off – Please complete & sign.

In signing this section, you are confirming the applicant has a DBS completed and verified by the employer and is of good health and character. Please note: We do not require a copy of the DBS.

Line Manager Name:	Click or tap here to enter line manager name.
Signature: Please sign - wet or electronic signatures are accepted, we cannot accept typed names.
Date signed:	Click or tap to enter date signed.

Practice Supervisor Requirements

You are required to identify a practice supervisor prior to enrolment on the course. The practice supervisor needs to be a registered Medical/Clinical Practitioner and should be at least at SHO or advanced level. Alternatively, an Advanced Care Practitioner may take on this role (ie. nurse, physiotherapist, occupational therapist or paramedic who has completed an advanced practice course and has experience of performing assessment on students).

It is the students’ responsibility to identify a supervisor, and they should be mindful of the opportunities for supervision when selecting this person.

Practice Supervisor Details – To be completed, dated and signed by Practice Supervisor. Please ensure the contact details are correct as the University will be in contact to verify supervision is in place.

Practice Supervisor name:	Click or tap here to enter practice supervisor name
Practice Supervisor email address:	Click or tap here to enter practice supervisor email address.
Regulatory body	Choose professional body (NMC, HCPC, GPhC, or Other).
Professional body pin:	Click or tap here to enter pin.
Signature: Please sign - wet or electronic signatures are accepted, we cannot accept typed names.
Date signed:	Click or tap to enter date signed.

Processing Personal Data

The University of Essex will hold and process your personal data for the purposes of maintaining your academic and related records. The information supplied on this form will be processed in line with the Data Protection Act 2018 and the UK General Data Protection Regulations. It will be kept secure and accurate and will only be disclosed in line with the law. Your attendance and Examination Board ratified module marks will be shared with your sponsoring Trust. If you do not wish this to happen, you are responsible for asking your line manager to communicate with the School to this effect. Further information on how the University of Essex processes your personal data is available on the Privacy Policy for students, which can be found on the University’s Privacy Hub. Please note that the information on this application form is required for registration purposes only.

Please ensure sections requiring a signature have a wet or electronic signature, we cannot accept typed names.

Applicant Signature: Please sign - wet or electronic signatures are accepted, we cannot accept typed names.
Date signed:	Click or tap to enter date signed.

Applicants employed and funded by the NHS, please send this application form to your NHS Funding Team/Training Team, who will arrange for the funding authorisation section to be completed to confirm the funding is approved and will submit your application on your behalf to cpd@essex.ac.uk. For all other applicants, please sign and date the application and email it to cpd@essex.ac.uk / Senior Contracts Manager, School of Health & Social Care, University of Essex, Wivenhoe Park, Colchester, Essex, CO4 3SQ.