Department of Pharmacy
Independent
Prescribing Course
Additional Information
To apply: Please complete all sections of the form electronically, ensuring where signatures are required that these
pages are scanned. Please upload this to your Kings application via the portal. The course fee for the 2015-16
academic year is £2,400.
Closing date: The closing date for applications is 5pm Monday 18th July for entry to the September 2016 course.
Please bear in mind that applications will be reviewed after the deadline with applicants being informed within the
next two weeks whether they have been successful.
1 Employment Details
Name and address of current employer(s)
Position
Date
Provide evidence below of relevant ‘patient orientated practice’ in hospital / community / primary
care
Application Form September 2016
Page 1 of 9
2 Pharmacy Regulator Details
Name as it appear on General Pharmaceutical Council / PSNI Register
General Pharmaceutical Council (GPhC) or Pharmaceutical Society of Northern Ireland (PSNI)
registration number on practicing register
Date of registration GPhC/PSNI
3 Medical Practitioner Details
Competency Statement Medical Practitioner
A Medical Practitioner with whom you work with as a pharmacist providing 'patient orientated services'
should sign the following
Outline of service provide by the applicant:
I confirm that
(insert pharmacist’s name) provides the above service and that they
have relevant patient oriented practice to develop the independent service outlined below in section 4.
Signed …………………………………………………………. Date……………………
Name in block capitals
Work Address
Application Form September 2016
Page 2 of 9
4 Outlining the independent service you want to offer, developing your
scope of practice
Outline your intended prescribing scope of practice linked to your relevant ‘patient orientated
practice in hospital / community / primary care’. Initially, you will be a NOVICE prescriber. It may
therefore not appropriate to align your prescribing scope of practice to your broad scope of practice
as an experienced pharmacist. For example, it would not normally be acceptable to include the
treatment of a complex medical condition AND to include all supporting medications for that
condition within your scope of practice when completing this course.
Please describe below which groups of patients and diseases states you are planning to prescribe for
and in what setting
Group(s) of patients:
Disease state(s):
Setting:
Outline the class(es) of drugs (we recommend no more than three) that you will use to
demonstrate competence and to support the development of your portfolio linked to your scope
of practice for the purpose of this course. Please contact the course leaders for clarification if
required.
1
2.
3.
Other
Applicant’s declaration
I understand the GPhC’s requirement to attend all taught sessions throughout this course, and that I
have the appropriate level of professional indemnity insurance.
Signed …………………………………………………………. Date
Application Form September 2016
Page 3 of 9
Please provide information about the organisation for whose patients you intend to prescribe
5 Supporting Organisation Details
About your ‘Supporting Organisation’
Your supporting organisation is the organisation whose patients you will prescribe for. For NHS patients
this could be a primary care organisation, hospital trust or GP practice. For private patients this could be
a private hospital or clinic.
Name of organisation
Address
NB If prescribing in primary care to NHS patients it is strongly recommended that you have the support of
your local primary care organisation as they will be able to request NHS prescription forms for you.
The name and address of a senior manager or practitioner in your supporting organisation who can
confirm



You have at least two years of appropriate patient orientated experience in a hospital,
community or primary care setting after your pre-registration year
You have up-to-date clinical, pharmacology and pharmaceutical knowledge relevant to this
identified area of prescribing practice
You will be able to adhere to the organisation’s non-medical prescribing policy
Name
Job title
Supporting organisation:
Address
Signature……………………………………………………………..
Application Form September 2016
Page 4 of 9
The Information required for section 6& 7, are entry requirements for the prescribing course as stipulated by the
General Pharmaceutical Council
6 CPD details
Description of on-going CPD
Briefly describe below how you have reflected on your own performance as a pharmacist providing patient
orientated services and taken responsibility for your own CPD. This should be associated with your proposed
scope of practice. In addition to the descriptions below please submit two CPD records of events and
reflective accounts completed relating to your proposed scope of prescribing (you should attached these as
PDFs using the recognised GPhC CPD format)
7 Prescribing Network Details
Development of your prescribing network
Describe below how you will develop your own networks for support, reflection and learning, including
prescribers from other professions
Application Form September 2016
Page 5 of 9
Confirmation of Information required for application to the Practice Certificate in Independent Prescribing
Please tick the box to confirm the statements below
Tick if correct
I am currently registered with the GPhC / PSNI
I have at least two years of appropriate patient orientated experience in a hospital, community
or primary care setting after my pre-registration year
I have up-to-date clinical, pharmacology and pharmaceutical knowledge relevant to the
identified area of prescribing practice
The relevant independent prescriber(s) in my organisation have agreed to support the
introduction of non medical independent prescribing
I have NOT previously been enrolled on a course at another institution leading to a Practice
Certificate in independent Prescribing
I have an agreement with a Designated Medical Practitioner to supervise my time in practice –
representing a total of 90 hours (equivalent to 12 days in practice)
I do not manage/supervise or have a close personal relationship with my Designated Medical
Practitioner
A professional relationship must exist between the student and the DMP they should not be a close family
member or someone that you supervise or manage .
I have secured funding for the course fees from my employer
If the applicant is being funded by an employer / sponsor please provide the following details*:
Funding Organisation:
Contact Name:
Contact Address:
Name of Senior Manager/Practitioner
Signature of Senior Manager/Practitioner……………………………….
*The invoice will be sent to the person and address provided above
I intend to pay my own course fees
Application Form September 2016
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8 Applicant’s Statement
I confirm that the information I have provided above in support of my application to the Independent
Prescribing course is correct
Fitness to practice: False Declarations
Please note, the Pharmacy Department King’s College London would be obliged to pass on to the College
Fitness to Practice Committee the names of applicants that have deliberately falsified information given above
to support their application to the course
In addition, if you have been sponsored to undertake the Practice Certificate in Independent Prescribing, it is
YOUR responsibility to disclose the result of the assessment to your sponsor.
Name in Full
………………………………………………………………………………….
Signature…………………………………………………………………….Date………..
Application Form September 2016
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9 Designated Medical Practitioner’s Statement
Section - To be completed by the Designated Medical Practitioner
Name (please print)
.......................................................................................................................
Organisation (please print)
Address (please print)
.........................................................................................................
..................................................................................................................
Email address (please print)
........................................................................................................
Phone number (please print)
.......................................................................................................
DMP training, you are encouraged to make every best effort to attend this training with the student. It
is anticipated that you will clarify the learning contract and the scope of practice following this joint
training session and gain a broader understanding of the programme and your role. Please indicate
below whether you will attend the programmed session:
September 2016 Cohort
Tuesday 27th September 2016: - Training session 1
14:30 to 16:30
Background experience
Please answer the following questions regarding your clinical experience and role as a DMP.
Job title (please state)
...................................................................................................................
Please indicate below if you have previously been a Designated Medical Prescriber (tick all those which
apply)
Pharmacist on the King’s College London Practice Certificate in Independent prescribing
Pharmacist on the King’s College London Supplementary Prescribing Course (ended January 2008)
Pharmacist on the King’s College London Supplementary to Independent Prescribing Course
Nurse / midwife on the King’s College London Independent prescribing Course
Nurse / midwife on the King’s College London Supplementary Prescribing Course
Pharmacists / nurse / midwife on another Independent prescribing Course
Please state the university
Application Form September 2016
.....................................................................
Page 8 of 9
Please indicate below your current experience of supervision, support and assessment of trainees in
practice (please tick all those which apply).
GP trainees
Nurses
Medical students
Pharmacists
Other health care professional
Junior Doctors
Please state
…………………….
Please indicate below if you current hold the any of the following qualifications (please tick all those
which apply).
Relevant qualification doctor/dentist to act as a Designated Medical Practitioner
Joint Committee for Post-graduate Training in General Practice Certificate
A specialist registrar, clinical assistant or a consultant within a NHS Trust or other NHS
employer.
Other (please state)
.....................................................................................
Does the practice environment provide sufficient opportunities to meet learning outcomes of a
pharmacist to become a non medical prescriber within the stated scope of practice?
Yes
No
Has protected time been allocated to allow you to regularly meet with the trainee pharmacist non
medical prescriber to undertake days in practice and to review their progress?
Yes
No
Please describe the opportunities available in the practice environment (please detail below)
I have agreed to act as (insert student’s name)
…………………………………………………………….…..
Designated Medical Practitioner (DMP) during the 90 hrs in practice that form part of the course for
pharmacist independent prescribing
I can confirm that I meet the standards as required in NHS guidance for the role of DMP
Has normally had at least three years recent clinical experience for a group of patients / clients in
the relevant field of practice.
Is within a GP practice and is either vocationally trained or is in possession of a certificate of
equivalent experience from the Joint Committee for Post-graduate Training in General Practice or is a
specialist registrar, clinical assistant or a consultant within a NHS Trust or other NHS employer.
Has the support of the employing organisation or GP practice to act as the DMP who will provide
supervision, support and opportunities to develop competence in prescribing practice.
Has training and experience in the supervision, support and assessment of trainees in practice
Is willing to participate in the assessment process of the pharmacist independent prescriber
Full Name:
Signed …………………………………………………………….Dated……………………………
Application Form September 2016
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