Student placement enrolment form
This form is to be used to arrange the enrolment of students with placements at the IoP.
The form should be completed by the student and the supervisor, and be submitted at least one month before
enrolment is due to take place, to:
Robina Cloralio
Education Support Team, IoP
PO Box 0090
robina.cloralio@kcl.ac.uk
In order to qualify for this scheme, the student should be:
a) Studying as an undergraduate at another UK Higher Education institution
b) Undertaking the placement as an accredited part of their studies
Students not meeting this definition will be taken through the Visiting Appointment process by IoP HR.
Section 1: to be completed by the student
A Personal Details
*
Surname/Family Name
*
First Names
Name in which you are
registered with a professional
body (if applicable)
Title
*
Date of birth
Address
*
Postcode/ Zip code
Home Telephone
Email Address
*
Country
Mobile Telephone
B Fee and visa status
Country of birth
Country of permanent residence
Nationality
Are you currently studying on a
Tier 4 student visa?
 Yes
No
C Education & Professional Qualifications
Include in this section all the relevant qualifications. Please also indicate subjects currently being studied.
Subject/Qualification
Place of Study
Grade/result
D Details of Current Programme of Study
Please confirm the following information
Name of current UK institution of
study
Will this placement form an
accredited part of your degree
programme?
 Yes
No
Name and contact details of placement liaison officer in your institution of study
Name
Address and postcode
Telephone
Email Address
E Duration
Proposed starting date
Duration of placement
Proposed end date
Year (start/end)
F – Emergency contact details
*
Surname/Family Name
*
First Names
Address
*
Postcode/ Zip code
*
Country
*
Home Telephone
*
Mobile Telephone
Email Address
Relationship of emergency
contact to you – e.g. mother,
partner etc.
Student Agreement
I have read and agree to the terms of the Student Placement (see appendix 2), and have completed the
information on disability (appendix 3) and submitted this separately
NAME ……………………………………………………………………………………………………..
SIGNATURE …………………………………………
DATE …………………………………
Section 2: to be completed by the supervisor
A Supervisor Information
Name and contact details of supervisor
Name
Address and postcode
Telephone
Email Address
B
Placement details
Proposed starting date
Duration of placement
On the first day the candidate should
report to:
Location
Weekly Stipend amount (if applicable):
Will travel expenses be paid?
 Yes
No
Address where the student will be based:
Room Number
Floor
Building
Campus
Telephone
Will the student need to gain DBS and/or Occuapational Health clearance in order to perform their duties? Please click on the link below for
information relating to clearance requirements
https://internal.kcl.ac.uk/iop/stu/pgr/assets/clearanceforpgr.docx
DBS clearance required
 Yes
No
Occupational Health clearance
required
Will the student require access to
SLaM or any other NHS Trust?
 Yes
No
Name of Trust (if applicable)
 Yes
No
This Student Placement is for the purposes of contributing to the student’s academic attainment
and the department would not normally offer this position to any person
Department agreement
I have completed this form and am fully aware of the basis on which I am agreeing to supervisor this
student. I have informed the student of the arrangements for payment of stipend/expenses.
Supervisor’s name: …………………………………. ……Signature ………………… Date …………………….
Head of Department’s name ……………………….. ….Signature …………………… Date ………………….
Business Manager’ name ……………………………….. Signature ………………….. Date …………………….
Please submit to Robina Cloralio in EST once completed and signed.
For completion by Education Support Team
Date of EST appointment (first day if
possible)
Student provided with DBS & OH info?
Time of appointment
 Yes
Not required
Honorary Contract necessary?
 Yes
No
Student should bring their passport and any Visa documentation when enrolling
…………………………………………………………………………………………………………………
Notes
…………………………………………………………………………………………………………………
…………………………………………………………………………………………………………………
Please return to departmental Business Manager once approved and appointment arranged.
Appendix 1: Payment authorisation for IoP Student Placements
INSTRUCTIONS FOR COMPLETION
If only one payment is required, please use the form 'Expenses Claim for KCL Staff, Students and Non-Staff'.
Please complete all details in full.
If amounts are subsequently required to be increased, please submit a further spreadsheet for the additional
amount only, not the revised figure as duplicate payments could result.
Please note: Payments may be set up for a maximum period of 36 calendar months in advance.If payment is
required beyond that, a further request is necessary at that time.
The named supervisor is directly responsible for ensuring all payments made are within the terms and
conditions of the sponsor and the budget provided.
Monthly Student Placement Funding Request
Supervisor Details
School …………………………………………………. Division/Dept ……………………………………………….
Full Name ……………………………………………………………………………………………………………………
Email Address………………………………………………………………………………………………………………
Authorised Signatory
Full Name………………………………………………. Signature………………………………………………………
Placement Student
Student Name…………………………………………………………………………………………………………..
Parent University……………………………………………………………………………………………………..
Name of Bank (UK Bank only)……………………………………………………………………………………..
Sort Code ……………………………
Account Number…………………………………........................
Payment Details
1st Payment
Due Date **
(ie 01/10/****)
Last Payment
Date
(ie 01/09/****)
Total of
Yearly
Amount
£
No. of
Equal
Instalments
Monthly
Account code
[XXXXXX-XXX]
NB Not a salary
code
YEAR 1
YEAR 2
YEAR 3
END OF PERMITTED REQUEST
**(ie if the student stipend runs from 1st October but the student arrives after this date, the due date must still be entered
as the 1st of October to ensure arrears are calculated accordingly)
Please return this form to Bought Ledger, James Clerk Maxwell Building, King’s College London
Appendix 2: Student responsibilities during the placement
Behaviour
You will be expected to be courteous and respectful to other staff, students and clients during your
placement.
Transport and Lunch
You will be responsible for making arrangements for transport and lunch.
Health and Safety:
You must:

take reasonable care to avoid injury to yourself or to others
report any accident or injury immediately and record the details according to KCL Health & Safety
procedures.
You must not:
interfere with, or misuse any clothing or equipment provided to protect your Health and Safety.
Confidentiality:
You must not, at any time whether during or after the placement, disclose to a third party, any confidential
information you obtain during your placement.
IT Access: (applicable to students given access to Information Systems)
You might be granted IS access during your placement. Whilst using KCL IT systems, you must comply
with the KCL Data Protection and Confidentiality Policy.
Appendix 3: Disability and ethnicity information - to be completed by the
student
Please note that information collected within this part of the form will NOT be submitted for academic
assessment
Disability Discrimination Act 1995
The Disability Discrimination Act protects disabled people. This includes people with long-term health conditions. If you tell us that you have a
disability we can make reasonable adjustments to your work arrangements and at interview.
Name
Date of birth
 Yes
 I do not wish to disclose this information
* Do you consider yourself to have a disability?
No
If you have a disability do you require any specific arrangements to enable you to attend for interview?
Yes
 No
N/applicable
If yes, please supply details below:
Please state the type of impairment which applies to you. People may experience more than one type of impairment, in which case you may
indicate more than one. If none of the categories apply, please mark ‘other’.
 Physical Impairment

Learning Disability/Difficulty
 Sensory Impairment

Long-standing illness
 Mental Health Condition

Other
Ethnic Origin
Equality monitoring is important in helping the College to ensure our Equality and Diversity Objectives are relevant and effective, which is why we
need to collect the following information from all potential students. Any data collected will be stored securely and used anonymously for equality
monitoring purposes only. The contents of this section will be treated in strict confidence.
Please select the option which best describes your ethnicity
 Asian - Bangladeshi

Asian - Other
 Black - Caribbean
 Other
 White and Asian
 Asian - Chinese

Asian - Pakistani
 Black - Other
 Other Mixed
 White Black African
 Asian – Indian

Black - African
 Not Given
 White
 White Black Caribbean
Please detach this form and send it separately to:
Robina Cloralio
Education Support Team, Institute of Psychiatry
King’s College London
De Crespigny Park
London SE5 8AF