Community Formulary Prescribing (V150)
Community Practitioner Nurse Prescribing (V100)
Supplementary Information Form
To be completed & returned in addition to the standard Anglia Ruskin Online
Application form to:
Admissions CPD Team, UK/EU Admissions, Anglia Ruskin University, Bishop Hall
Lane, Chelmsford, CM1 1SQ. Alternatively please email a scanned copy to
admissionscpd@anglia.ac.uk
If you are funded through a Trust please also send a copy of this form to your
Education Liaison Manager.
1. PURPOSE:
The Community Formulary Nurse Prescribing V150 course is a GENERIC
COURSE that will equip practitioners with the PRINCIPLES OF PRESCRIBING
within the Nurse Prescribers Formulary.
It is taught alongside the V100 (Community Practitioner Nurse Prescriber) and
V300 (Independent and Supplementary Nurse Prescriber) prescribing courses as
much benefit can be gained from learning alongside other health care
professionals.
It is expected that all applicants to the Community Formulary Nurse Prescribing
V150 module are fully competent in the clinical treatment and care of their
specific clinical area before starting the module.
This checklist is intended to assist potential candidates and their employers in
identifying and prioritising candidates for independent/supplementary prescribing
preparation. It also doubles as a nomination form for individual candidates.
Employers have a responsibility to ensure that candidates nominated fit the
eligibility criteria and have the support of their employers to go forward for the
course.
NB. CANDIDATE, EMPLOYER & NURSE PRESCRIBER MENTOR TO SIGN
APPLICATION FORM
2. IDENTIFICATION
The candidate must demonstrate all of the following:
YES NO
A first level nurse, midwife or specialist community public health nurse
registered with the NMC with at least two years post-registration
experience of which the year immediately preceding commencement must
be within the clinical area in which the candidate will be practising as a
Community Formulary Nurse Prescriber
(Please note the mentor must have the V100 or V150 Community
Practitioner Nurse Prescriber Qualification recorded on the NMC
register).
Has undertaken CRB check for current employment
*
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The candidate must demonstrate all of the following:
YES NO
*If no please attach copy of CRB application as evidence that this has been
applied for.
Is the candidate able to demonstrate ability to study at level 3 (1st degree
level)?
Has identified a service need in conjunction with employer requiring the
candidate to undertake Community Formulary Nurse Prescribing.
training.
Has employer given commitment to:
- Candidate’s attendance on the programme?
Has employer given commitment to:
- Provision of continuing professional development?
Has employer given commitment to:
- Provision of a Designated Nurse Prescriber as Mentor? (Practising V100
or V150 prescriber – usually a Health Visitor or District Nurse, trained as
mentor)
Is the candidate able to demonstrate appropriate numeric skills (usually a
GCSE maths or Learn Direct level 2 Numeracy)
Nurse and midwife candidates:
Is the candidate able to provide evidence of assessed as competent to
take a history, undertake a clinical assessment and diagnose before
accessing the module? The candidate may undertake a further module
concurrently to meet this requirement.
Is the candidate currently enrolled on a recognised credit bearing
consultation/assessment/diagnostics skills module or condensed
consultation and assessment non-credited course? Please provide course
title, start date of course and education provider below:
OR: Has the candidate completed a recognised credit bearing
consultation/assessment/diagnostics skills module? Please provide course
title, date of award and awarding institution below:
OR: Has the candidate completed a recognised condensed consultation
and assessment non-credited course? Please provide course title, date of
course and education provider below:
OR: Has the candidate demonstrated within their knowledge and skills
framework that they are regularly undertaking specialist assessments
within their role
*If yes, the candidate’s line manager needs to complete attached form 1 to
confirm.
*
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The candidate must demonstrate all of the following:
YES NO
Is the candidate employed within the NHS or GP Practice?
Has employer given commitment to:
- Access to a prescribing budget and other necessary arrangements for
prescribing practice?
Is the candidate employed within private practice?
*If yes, please state source of funding.
*
Has a Nurse Prescriber Mentor (V100 qualified and trained mentor) been
identified?
Please supply name and address:
Does the Nurse Prescriber Mentor agree to be a mentor to a student
undertaking the course?
Is the Nurse Prescriber Mentor a practising prescriber?
Has the Nurse prescriber Mentor undertaken a recognised mentorship
qualification (ENB 998, MiPS, CPT etc) and undertaken a mentorship
update in the last year
Does the Nurse Prescriber Mentor have the approval of the employer to
undertake the mentoring role?
Has the Nurse Prescriber Mentor completed the attached mentorship
agreement form (form 2)? Please return it with the application form.
Have you applied and commenced a programme of prescribing preparation
previously? If yes, please list reason for non completion below:
Signature of candidate ……………………………………………………………………….
Signature of
Education Liaison Manager………………………………………………………………….
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FORM1: SUPPLEMENTARY EVIDENCE
EMPLOYER CONFIRMATION OF ABILITY TO DIAGNOSE IN
CANDIDATE’S AREA OF SPECIALITY
Please complete the following information in block capitals:
Applicant Name:
Applicant Job Title:
Area of Speciality:
Name of Line Manager:
Name of Employing Organisation:
On behalf of the employer I confirm that the above named applicant has been assessed as
competent to take a history, undertake a clinical assessment, and diagnose. I am aware that
registrants should not be put forward for the Community Formulary Nurse Prescribing course
if they have not demonstrated the ability to diagnose in their area of speciality*.
Signature of Line Manager:……………………………………………………………………….
Date:………………………………………………………………………………………………….
*NMC guidance states “it should be possible to identify whether a registrant has these skills
through Continuing Professional Development (CPD) reviews within the work place setting”
2. UNDERTAKING CRIMINAL RECORDS BUREAU (CRB) CHECK
On behalf of the employer I confirm that the above named applicant has undertaken a CRB
check within their current employment in the last 3 years. .
* If no , please attach copy of CRB application as evidence that this has been applied for.
Date of CRB or DBS check ………………………………….
Signature of Line Manager:……………………………………………………………………….
Date:………………………………………………………………………………………………….
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FORM 2
DESIGNATED PRESCRIBING PRACTITIONER SUPPORT
MENTORSHIP AGREEMENT FORM
The Nurse Prescriber Mentor has a crucial role in educating and assessing non-medical
prescribers. This includes:
 Establishing a learning contract with the student
 Facilitate learning through critical thinking and reflection
 Provide dedicated time and opportunities for the student to observe how the mentor
conducts a consultation/interviews the patient/carer and develops a management
plan
 Allow time for the student to carry out consultations and suggest clinical management
plans and prescribing options which are discussed with mentor
 Allow for the development and integration of theory and practice
 Give opportunities for in-depth discussion and analysis of clinical management plans
using random case studies where patient care and prescribing behaviours can be
discussed further
 Assessing and verifying that by the end of course the student is competent to take on
the community Formulary nurse prescribing role
Section A – To be completed by the candidate (Please print)
Name of Candidate:
Work Contact Details (Address, Tel. No., e-mail and fax if available)
Section B - To be completed by the Nurse Prescriber Mentor (Please print)
Name of Nurse Prescriber Mentor:
Designation and Professional Qualifications:
(please note the mentor must have the V100 Community Practitioner Nurse Prescriber
qualification recorded on the NMC register and be an up to date mentor)
Work Contact Details (Address, Tel. No., e-mail and fax if available):
I have discussed the Nurse Prescriber Mentor role with the above candidate and have the
support of my employer to provide 10 days (65 hours) practice based training. I agree to
undertake the role and to access the preparation provided.
Signature of the NPM ……………………………………………………….
Date…………………
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