Request for Practice Experience (Non Commissioned Programmes)
Please note that each request may incur an administration fee of £150
Name of student:
Contact Details:
Mobile:
Email:
University:
Programme of Study:
Name of Academic Tutor:
Contact Details:
Practice Experience Dates
Practice Experience Area:
From:
To:
Reason for application to IOW NHS Trust:
Do you intend to seek employment with IOW NHS Trust on qualification: YES / NO
Learning Outcomes:
Supervisory / Mentorship Requirements:
The following evidence is required before any offer of a placement can be considered.
Evidence of the following Statutory & Mandatory
Training (UK Core Skills Framework):
Date of Completion
Conflict Resolution:
Evidence of the following is required:
Covering letter from University authorising
placement request:
Equality, Diversity and Human Rights:
DBS Enhanced Clearance
Disclosure Number:
Date:
Fire Safety:
Occupational Health Level 2 Clearance (Date):
Health, Safety & Welfare:
Reasonable adjustments required? Yes/No
Infection Prevention & Control:
If yes please provide details:
Information Governance:
Moving & Handling:
Resuscitation Adult:
Resuscitation Paediatric (if applicable):
Safeguarding Adults:
Safeguarding Children:
Signature of applicant:
Date:
Once completed please return completed form to:
Clinical Education Team | Education Centre | Isle of Wight NHS Trust | St Marys Hospital | Parkhurst Road
| Newport | Isle of Wight | PO30 5TG
Tel: 01983 822099 ext 6428
Email: clinicaleducationteam@iow.nhs.uk
For office use only:
Outcome: Evidence satisfactory? YES /NO
If no please state reason.
Is University covered by a PPA? YES/NO
If NO an honorary contract is required. Please forward this form to HR to generate