Dear Student Nurse,
Welcome to the School of Nursing & Midwifery at Trinity College. We are
delighted that you have been offered a place on the Bachelor in Science
(Nursing) course.
The course will begin 21st September 2015 (Full time) and you are required to
attend the School of Nursing & Midwifery, 24 D’Olier Street, Dublin 2, at 09.00
a.m. sharp.
You should by now have received a message in your intray via Student
Information System (SITS) access via my.tcd.ie where you have been asked to
select your training hospital/service for the Bachelor in Science Nursing course.
If you have not completed this process then you should do so now.
To complete the process you should now print, complete and return the
following forms to address provided below:
A. Self-Declaration pre Garda clearance
B. Confidential Health Self-declaration Form
 All forms must be returned on or before the 1st September 2015.
Note: Offers received in Round 2 and thereafter, please return forms as
soon as possible upon receipt of your orientation pack.
Please note: All offers of admission are subject to satisfactory completion of
required forms. Students will not be permitted to register until all forms have
been received and reviewed by the School of Nursing and Midwifery.
Information contained on these forms will be forwarded to the hospital /
health service provider to which you are allocated.
Looking forward to meeting you on 21st September 2015.
Kind regards,
Pádraig Dunne
Clinical Allocations Officer
A. Self-Declaration pre Garda clearance
The self-declaration seeks information on the student’s suitability for the
practice element of the programme. It is particularly important for Health
Service Providers as they must ensure their clients’ safety at all times. Only if
for any reason you are unable to consent/agree then you are required to print
off the form and sent to the Administrative Officer Clinical Allocations, The
School of Nursing and Midwifery, Trinity College, Dublin 2. Failure to either tick
or submit form may cause delays in registration for your JF year. Please seek
advice on the completion of this form from vetting units if you are unsure of
disclosing anything.
B. Confidential Health Self-declaration Form
The confidential health self-declaration form is designed to allow you to identify
any health issues that you feel may impact on your programme. It is in your
best interest to identify any physical or mental health conditions that may later
have an impact on your ability to satisfactorily complete the practice element of
the programme. Several support service exist in TCD regarding physical or
mental conditions and support for students during their college years, early
disclosure will expedite supports required.
All of these forms must be completed and returned by the relevant date outlined
above to:
Administrative Officer -Clinical Allocations
School of Nursing & Midwifery
Trinity College Dublin
24 D’Olier Street, Dublin 2
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SELF DECLARATION (PRE GARDA CLEARANCE )TO BE
COMPLETED BY NURSING STUDENTS
NAME: (please print) _____________________________
CAO NUMBER: _________________________________
1.
I have been informed and understand that if I give a false certificate
regarding any of these matters, the School of Nursing and Midwifery of
Trinity College Dublin will immediately terminate my participation in the
programme, which I am attending.
I have never in the past been convicted of any criminal offence, nor is
any prosecution pending against me for assault, battery, rape, murder,
false imprisonment, unlawful carnal knowledge, theft or forgery.
I have also never in the past been convicted of any criminal offence, nor
is any prosecution against me pending relating to the trafficking or
possession of drugs for supply.
I am not and have never been engaged in any conduct, which could
result in a conviction for any offence under the Child Pornography Act
1998. I understand that the offences under the Act comprise child
trafficking, the taking of children for the purpose of sexual exploitation,
allowing children to be used for the production of child pornography, the
dissemination of child pornography and the possession of child
pornography.
I have never been excluded from working with children.
2.
3.
4.
5.
I certify that the above information is correct.
Signed: ______________________Date: _____ day of ___________ 2015
6.
I
agree
to
abide
by
the
Code
of
Conduct
(http://www.nursingboard.ie/en/policies-guidelines) currently in force for
students who are not registered nurses as set out by the School of
Nursing and Midwifery, and I agree to abide by this code as
subsequently amended from time to time
.
I consent to this information being passed on to the Health Service
Provider to which I am allocated.
Signed: ______________________ Date: _____ day of ___________ 2015
Please complete this form and return it to: The Allocations Office, Trinity
College, School of Nursing and Midwifery, 24 D’Olier Street, Dublin 2.
NB Please contact the Allocations Office, in the School of Nursing and
Midwifery if, for any reason, you are unable to sign this form.
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Confidential Health Self Declaration
(To be completed by the Nursing Student)
Name:
(Please
_____________
print)
Address:
____________________
________________________CAO
Number:
______________________________Telephone:
Do you have any disabilities or significant on-going illnesses, which could delay
or prevent your start or completion of the Nursing Degree Programme or give
rise to difficulties on practice placements?
Yes
No
If yes, please provide further details:
______________________________________________________________
______________________________________________________________
______________________________________________________________
______________________________________________________________
This information will be forwarded by the Allocations Office to the Hospital /
Health Service Provider, to fulfill part of its required health screening process
prior to you commencing your initial practice placement. If following this process
the Hospital/Health Service Provider is of the opinion that you in fact have a
disability or significant on-going illness, which could delay or prevent your
completion of the programme, your registration as a student in the programme
will be reviewed.
Consent: I consent to the following:a. The provision of this information to the Hospital/Health Service Provider
mentioned above).
b. Being medically screened by or on behalf of the same Hospital/Health
Service Provider.
c. To the Hospital/Health Service Provider seeking further information from
any medical adviser whom I have attended concerning anything which
affects my disability or significant on-going illness if deemed necessary and
I undertake to supply it upon request with the name(s) of my medical
adviser(s).
Signed: _____________________(Applicant) Date: ___________________
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Declaration and Acknowledgment: I confirm that the answer to the above
question is accurate to the best of my knowledge at the time of signing this
Declaration. I acknowledge that any failure by me to disclose information or any
submission by me of the information which is subsequently found to be false or
misleading, or any opinion of the Hospital/Health Service Provider that I in fact
have any disabilities or significant on-going illnesses that would delay or
prevent my completion of the Nursing Degree Programme may entitle the
College to review and consider my participation in the BSc Nursing programme.
Signed: __________________ (Applicant)Date: ______________________
Please complete this form and return it to: The Allocations Office, Trinity
College, School of Nursing and Midwifery, 24 D’Olier Street, Dublin 2.
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