University
Level of
Study
Level 6 – Degree
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Type of
Prescriber
Supplementary
(Radiographer)
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Independent /
Supplementary
Nurse (V300)
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Applicant Name
Date of Birth
Profession Nurse/Midwife
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Pharmacist
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Start Date
Level 7 – Postgraduate (not available for V150 students)
N/A Staffs
Uni
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Community
Practitioner
(V150)
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Independent / Supplementary
Physiotherapist / Podiatrist / Optometrist /
Pharmacist
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Allied health professional
Physiotherapist
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Podiatrist
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Radiographer
Optometrist
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Job Title
Contact Details Work
Address and
Postcode
Telephone No.
Mobile No.
E-mail address
Tick preferred correspondence address
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Home
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Do you have a current enhanced DBS (current employer and
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 issued in last 3 years for nurses, and 3 months for AHPs)
If the answer to the above question is NO you must apply for an enhanced DBS clearance.
Please detail below the date of your DBS application:
Date of application: …………………………………..

PROFESSIONAL ELIGIBILITY (please complete section relevant to your professional background)
NURSING AND MIDWIFERY
Are you a 1 st level registered
Nurse/Midwife/Specialist Community Public Health
Nurse currently on the NMC register?
Yes

No
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Please state area of practice
Community Practitioner Prescribing (V150) only
Do you have at least 2 years or equivalent relevant post registration experience?
Yes 
No
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Yes 
No
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Independent/Supplementary Prescribers (V300) only
Do you have at least 3 years or equivalent relevant post registration experience?
NMC PIN number
ALLIED HEALTH PROFESSIONALS
Professional Group
Please state area of practice
Do you have at least 3 years or equivalent post qualification experience?
HCPC Registration number
Optometrist
Please state area of practice
Do you have at least 2 years or equivalent post qualification experience?
Expiry Date
Yes
No
Expiry Date
Yes

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No

Expiry Date GOC registration
Number
Pharmacist
Please state area of practice
Do you have at least 2 years or equivalent post qualification experience?
SPHC registration
Number
Yes
No

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Expiry Date

ACADEMIC REQUIREMENTS FOR PRESCRIBING
Highest Professional Qualifications attained e.g. Diploma/Degree in Nursing, Degree in Physiotherapy
Awarding Body Level Year Subject Result
NURSES ONLY
Please provide evidence of most recent study at degree/postgraduate level:
Place of study
Supporting Information (additional qualifications, professional experience likely to facilitate prescribing)
Have you registered or commenced and partially completed a non-medical prescribing course previously?
Yes *
No
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*If YES please give reasons for not completing the course

INDEPENDENT/SUPPLEMENTARY PRESCRIBERS - please complete the following section
Have you completed a health/clinical assessment course (or specialist equivalent)
Yes
No
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If NO - Staffordshire University require signed confirmation that you have been deemed competent, by an appropriate Professional Colleague, in clinical assessment and diagnosis prior to being put forward for this course (see professional regulations for guidance re competence). Please give details below and ensure that the relevant signature is obtained:
I confirm that the applicant is competent in clinical assessment and diagnosis and is a suitable candidate for non medical prescribing
(NB this may be achieved by internal assessment of competence or completion of an appropriate health/clinical assessment course)
Name (Print) Title/position
Signature Qualification
Please provide reasons for your application for a prescribing course a) How will your ability to prescribe maximise benefit to the patient? ( role/service delivery benefit, expected changes to clinical pathway, timeliness of provision, effectiveness, impact on patient journey/experience, improve access to medicines) b) How will your ability to prescribe benefit your organisation? (service improvements, financial improvements, skills utilisation, capacity improvements)
Please provide details of the service in which you intend to prescribe

DESIGNATED MEDICAL PRACTITIONER ARRANGEMENTS
Eligibility criteria for becoming a Designated Medical Practitioner (DMP)
Further information for supervisors is available on the Department of Health website
Are you a registered medical practitioner who: i) has normally had at least 3 years recent clinical experience for a group of patients/clients in the relevant field of practice
Yes
No and are you: ii) A) 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 Certificate
(JCPTGP )
Yes
No
OR
B) is a specialist registrar, clinical assistant or Consultant within a NHS
Trust or other employer
Yes
No and have you: iii) support of the employing organisation or GP practice to act as DMP who Yes
No will provide supervision, support and opportunities to develop competence in prescribing practice and have you: iv) some experience or training in teaching and or supervising in practice Yes
No
If not an Approved Training Practice/Institution , then please outline your experience of teaching, supervision and assessment of students
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AGREEMENT BY DESIGNATED MEDICAL PRACTITIONER FOR SUPERVISION OF APPLICANT
Please tick GP Consultant Specialist Registrar Clinical Other
  
Assistant
 
Speciality
Name of Medical Practitioner (Please print)
Work address
Telephone Number
E-mail address
I confirm that I have agreed to supervise, support and assess the applicant for a minimum of 12 days
(78hours) (for Pharmacists and AHPs this is 90 hours) in their prescribing role during clinical placement
Signature

COMMUNITY PRACTITIONER PRESCRIBERS (V150) ONLY COMPLETE THIS SECTION
Staffordshire University require signed confirmation that you have been deemed competent, by an appropriate Professional Colleague, in clinical assessment and diagnosis prior to being put forward for this course (see professional regulations for guidance re competence). Please give details below and ensure that the relevant signature is obtained:
I confirm that the applicant is competent in clinical assessment and diagnosis and is a suitable candidate for non medical prescribing
Name (Print) Title/Position
Signature Qualifications
Please provide reasons for your application for a prescribing course a) How will your ability to prescribe maximise benefit to the patient? (role/service delivery benefit, expected changes to clinical pathway, timeliness of provision, effectiveness, impact on patient journey/experience, improve access to medicines) b) How will your ability to prescribe benefit your organisation? (service improvements, financial improvements, skills utilisation, capacity improvements)
Please provide details of the service you intend to prescribe in (candidates are usually required to have worked for a minimum of 2 years in the area they will be prescribing in. Please indicate range of medication that you anticipate will be prescribed)
AGREEMENT BY MENTOR FOR SUPERVISION OF APPLICANT
Name
Job title
Work address
Telephone Number
Email address
Qualifications. Please include Mentorship with module codes
NB If your Trust/employer uses Electronic Staff Record (ESR) the date of your last update will be available to view there.
I confirm that:

The applicant is competent in clinical assessment and diagnosis and is a suitable candidate for non-medical prescribing

I have agreed to supervise, support and assess the applicant for a minimum of 10 days (960 hours) in the development of their prescribing role

I am a sign-off Mentor and will be on the live Trust Register of Mentors during the supervision period.
Signature
Print name
NMC PIN
Date

TRUST APPROVAL - LINE MANAGER CONFIRMATION
Please confirm the following:
Agreement for the applicant to be released for a minimum of:
Independent/Supplementary prescriber 26 study days with additional 78 hours
(nurses) or 90 hours (AHPs) learning in practice
OR
V150 Community Practitioner prescriber 10 study days, with an additional 10 days of supervised learning in practice as part of the non-medical prescribing course
The applicant has appropriate mentorship
The area of non medical prescribing activity is linked to core service provision
If the service is time limited or a pilot/service please give details below;
On qualification the applicant will have access to a prescribing budget and other practical requirements for prescribing
On qualification the on-going CPD requirements of the prescriber will be supported
I confirm that non-medical prescribing is included in the applicants Job description (JD) or a letter of empowerment to prescribe within the Trust will be appended to the JD
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Name (Please print)
Job Title
Work address
Telephone number
E-mail address
Signature Date

TRUST APPROVAL- AGREEMENT BY THE NON MEDICAL PRESCRIBING LEAD
Non Medical Prescribing Lead agreement that there will be access to a prescribing budget and a benefit to patient services by training this nominee
Name (Please print)
Organisation
Job Title
Work address
Telephone number
Email address
Signature
FUNDING

The following Trusts have a Learning Beyond Registration commission with the Faculty of Health
Sciences.
Staff from the three Trusts below will need to provide a signed module request form:

Burton Hospitals NHS Foundation Trust – Vannessa Rolinson

Robert Jones and Agnes Hunt Orthopaedic Hospital NHS Trust – Helen Smith/Jane Downey

Shrewsbury and Telford Hospital NHS Trust – Sarah Bloomfield/Philip Fewtrell
Staff from the following Trusts will need to provide the confirmation of funding letter they receive from their
Trust

Staffordshire and Stoke on Trent NHS Partnership Trust – Clare Spencer

Shropshire Community Health NHS Trust – Sonia Orr

If you are not being funded through LBR you will need to provide evidence of sponsorship at enrolment (This will usually be in the form of a Purchase Order)

APPLICANT (STUDENT) AGREEMENT
This application form is for the Non-Medical Prescribing course delivered by Staffordshire University
I (name) ............................................. am applying for the following course (please tick)
 Non Medical Independent/Supplementary Prescribing for Nurses and Midwives (V300) provided by Staffordshire University
 Non Medical Independent/Supplementary Prescribing for Allied Health Professionals
(Physiotherapy and Podiatry only) provided by Staffordshire University
 Community Practitioner Nurse Prescribing V150
I agree to communication between my employer, Prescribing Lead for my Trust and the University that I am attending to discuss any aspect of my attendance and progress on the prescribing course.
I confirm that I will attend all study days and complete the necessary supervised hours and examinations as required for the course.
On completion and following annotation by my regulatory body (NMC, HCPC) I will complete the appropriate approval to prescribe process.
I also agree to undertake Continuing Professional Development on completion of this course.
I confirm to the best of my knowledge, the information given in this form is correct and complete.
I have read and agree to comply with the guidance notes attached in Appendix 1.
Signature of applicant …………………………………
Date: ……………………………………………..