Centre for Professional Development & Lifelong Learning,
School of Pharmacy
Application Form
To Study Individual Modules as Short Courses or Part of Another
Programme
Return with the relevant course fee* and Equal Opportunities Monitoring form to:
Mrs Bev Oakden, Postgraduate Programmes Co-ordinator, School of Pharmacy, Keele University, Staffs
ST5 5BG or e-mail b.oakden@keele.ac.uk
* NB: no course materials will be dispatched until the course fee has been paid.
Clinical Pharmacy Programme
CPD Plus+ and CPD Plus+ Open Learn Courses/Modules
Please note that the availability of Open Learn courses/modules is subject to the programme manager’s
approval at any time. Please contact the programme manager to check availability before you apply
(d.knowles@keele.ac.uk; 01782 733561/734207).
PART A
Course Details
Start Date:
Module
Code
PHA-40049
PHA-40050
PHA-40051
PHA-40052
PHA-40053
PHA-40054
PHA-40055
PHA-40056
PHA-40057
PHA-40058
PHA-40125
PHA-40060
PHA-40061
PHA-40062
PHA-40063
PHA-40121
PHA-40065
PHA-40066
PHA-40067
PHA-40068
Mode of Attendance
CPD Plus +
10 credits
Module Title
Please tick one or more you wish to study
Education Theory and Practice for Health
Professionals (only for March/April start)
Surgical
Respiratory Disease
Renal Disease
Monitoring Therapy
Medicines Management & Pharmaceutical Care
Mental Health
Malignant Disease
Joint Disease
Infections
Neonatal and Child Health
HIV & AIDS
Cardiovascular Disease 1
Gastrointestinal Disease
Endocrine Disease
Quality in Healthcare & Evidence Based Practice
(only for January start)
Central Nervous System Diseases
Critical Care & Parenteral Nutrition
Cardiovascular Disease 2
Hepatic Disease
MOD
Open Learn
15 credits
Open Learn
30 credits
not available
not available
The following modules are available to study as part of the Clinical Pharmacy programme. Please contact
the Course Manager for further information.
PHA-40073 Advanced Practice Development
PHA-40099 Researching and Evaluating Your Practice
PHA-40116 Building Working Relationships for the Advanced Practitioner
PART B
Personal Details
First Names
Title:
Contact Address:
Postcode:
Country:
Telephone:
Fax:
Email:
Nationality:
Surname/Family Name:
Gender:
Country of Birth:
Date of Birth:
Telephone:
Fax:
Email:
Country of Residence:
PLEASE EXPAND THE BOXES BELOW AS NECESSARY TO PROVIDE THE DETAILS REQUESTED.
Academic and professional qualifications. Please include academic institution, degree
classification and year attended. NB You are required to send in a copy of your degree certificate
with your application form.
Details of professional registration body and personal registration number:
Current Employment. Please include your job title/role, employer’s name, address and date
employment started. NB Please send your employer's reference with your application form
If this module is undertaken as part of another programme please state
Institution
Course and Course
Number
Start Date
End Date
Briefly state reason for choosing module/s
Data Protection Act
The information contained in this form will be used for the purpose of processing your application and, if your application
is successful, will form the basis of your University record.
University Charter, Statute, Ordinances and Regulations
Registration at Keele University is conditional upon observation of the University’s Charter, Statute, Ordinances and
Regulations in effect at any time. A copy of the current version may be obtained from the University Secretary’s office or
is available on the web at www.keele.ac.uk/depts/vc/plansec/regs/reglist.htm
Please ensure that your application is complete and post together with a copy of your degree
certificate and a reference from your employer.
I hereby apply for admission to study at Keele University for the course set out above, and confirm
that the information provided is correct to the best of my knowledge.
Signature:
Date:
Postgraduate Programme in Clinical Pharmacy
Declaration of Support from the Student’s Workplace
Note for the workplace
The Clinical Pharmacy Programme has been developed specifically for hospital pharmacists. The course
learning materials, activities and assessments are designed to relate to actual clinical practice to make the
student’s learning experience more meaningful to their own environment. Students will require access to
patients and wards to enable the student to meet the course learning outcomes and complete work based
course work for the student’s Reflective Portfolio and other assessments. They will therefore need the
support of their workplace to access this information.
Students are advised that all information they use to help them complete their course work should remain
confidential and that no patients, colleagues, or other individuals should be named.
Respective students must arrange for this declaration form to be completed by an appropriate person in the
workplace, and submit it with their course application.
Please complete the details below in BLOCK print.
Student’s Name …………………………………………………………………………………………
Name of Supporter ……………………………………………………………………………………..
Supporter’s Organisation/Address …..……………………………………………………………….
……………………………………………………………………………………………………………
……………………………………………………………………………………………………………
Telephone ………………………………………….. Email address ………………………………..
Supporter’s Position in the Organisation ……………………………………………………………
I agree to provide the support required for the above named student to complete the course work for
the Postgraduate Programme in Clinical Pharmacy.
Signature ……………………………………………………………… Date …………………………
(Please ensure that this form is completed and returned with your application)
KEELE UNIVERSITY
EQUAL OPPORTUNITIES MONITORING
Please help us to make our equal opportunities policy effective by ticking the boxes
applicable to you.
ETHNICITY
11 White-British
12 White-Irish
13 White-Scottish
14 Irish Traveller
19 Other White Background
21 Black or Black British-Caribbean
22 Black or Black British-African
29 Other Black background
31 Asian or Asian British-Indian
32 Asian or Asian British-Pakistani
33 Asian or Asian British-Bangladeshi
34 Chinese Ethnic background
39 Other Asian background
41 Mixed-White and Black Caribbean
42 Mixed-White and Black African
43 Mixed-White and Asian
49 Other Mixed background
80 Other Ethnic background
90 Not known
98 Information refused
DISABILITIES
The University welcomes applications from people with disabilities and considers them on
the same academic grounds as those from other candidates. If you indicate on this form
that you have a disability, and if we make you an offer of a place, we will then inform our
Disability Services department who will contact you to discuss your support needs.
00 No known disability
If you have a disability, please indicate those which are applicable to you.
01 Dyslexia
02 Blind/ partially sighted
03 Deaf/ hearing impaired
04 Wheelchair user/ mobility difficulties
05 Personal care support
06 Mental health difficulties
07 An unseen disability, eg. diabetes,
epilepsy, asthma
10 Autistic Spectrum Disorder/
Asperger’s Syndrome
08 Multiple disabilities
09 A disability not listed above
(please specify)
Please return this form with your application form. Many thanks for your assistance.
Payment
Module costs from 1st August 2015:
10 credits - £460 / 15 credits - £690 / 30 credits - £1240 (for UK and EU students)
Full year (60 credits) - £2475
Payment can be made by cheque or debit or credit card (not Amex)
Cheque
I enclose a cheque made payable to Keele University for £________________
Card
Name on card:
___________________________
Card type:
___________________
Card number
Expiry Date
Valid From
Security code
Issue Number
(last three digits on reverse)
(where applicable)
Amount to be charged £______________
Cardholder Address:
_______________________________________________________
______________________________________________________________________________
_______________________________________________
Postcode
______________
Cardholder Contact Number
_________________________________________________
Student Name
(if different from cardholder)
_________________________________________________
Please return completed application form, equal opportunities form and payment to:
Mrs Bev Oakden, Postgraduate Programmes Co-ordinator, School of Pharmacy, Keele University,
Keele, Staffs ST5 5BG or e-mail b.oakden@keele.ac.uk