School of Nursing & School of Nursing & Midwifery
Return to Practice for Midwives Application Form
Module Code: NA5106 (Level 5) NA6156 (Level 6) Credits: 20
Incomplete forms will be returned
Aims
The aim of this module is to meet the professional outcomes to enable midwives to renew their midwifery registration
with the Nursing and Midwifery Council and re-enter registered practice with up-to-date competence, knowledge and
skills and confidence in order to maintain safe and effective standards of client care. It is also designed to establish the
concept of lifelong learning. At the end of the module midwifery returnees will have met the NMC (2010) PREP
Outcomes for Returning to Practice.
To enable the Return to Midwifery Practice Module to meet individual needs of each returnee, the programme has
adopted a work based learning approach. Thus study days and sessions will not be formally timetabled, but can be
negotiated as part of the returnee's individualised programme of learning. The returnee can access study days and
sessions with student midwives in the university setting and/or those run by the Trusts.
Summary
The returnee will be required to undertake a minimum of 60 hours of study which will take the form of attendance at study
days/sessions. Further time will be provided for the returnee to undertake self-directed learning/reflection. Clinical practice will take
place concurrently and the returnee will be required to undertake a minimum of 140 hours. (This will depend on the agreed length of
the Return to Midwifery Practice module).
The length of the module will be discussed and agreed at interview. It is expected, completion of this programme will be achieved in
six months (full time).
All clinical experience is based in one of the following NHS Trusts: Brighton and Sussex University Hospitals NHS Trust (RSCH
Brighton and Princess Royal, Haywards Heath); East Sussex Hospitals NHS Trust (EDGH Eastbourne and Conquest Hastings); and
Worthing and Southlands Hospitals (Worthing Hospital).
Entry Requirements
The applicants must have:
 Qualified in the United Kingdom as a midwife and to have previously registered
with the Nursing and Midwifery Council or have their qualification as a
midwife accepted by the Nursing and Midwifery Council with a requirement
to do a Return to Midwifery Practice programme and to be able to complete
their programme in 6 months full-time.
 Been accepted by a Trust for clinical placement.
 Attend an interview with the module leader and Head of Midwifery or her/his
deputy. The interview will include a numeracy and literacy test.
PLEASE KEEP A COPY OF THIS FORM FOR YOUR RECORDS
Form updated April 2011
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Application Process
If you are interested in the return to midwifery practice module and wish to discuss it further or want to apply please
contact:
Kim Hill
Senior Lecturer
Module Leader - Return to Midwifery Practice
University of Brighton
School of Nursing and Midwifery
Westlain House
Village Way
Falmer, Brighton
BN1 9PH
Tel:
01273 644054
email: K.R.Hill@brighton.ac.uk
You need to contact the Head of Midwifery at a local Trust to discuss a clinical placement.
Trust Contact details:

Brighton and Sussex University Hospitals NHS Trust (Brighton and Haywards Heath) –
01273 696955


East Sussex Hospitals NHS Trust (Eastbourne and Hastings) - 01323 417400
Western Sussex NHS Trust (Worthing Hospital) - 01903 285222
Professional Accreditation
Meet the NMC (2010) PREP requirements.
Contact
For further information please contact the University of Brighton module leader:
Kim Hill
Senior Lecturer
Module Leader - Return to Midwifery Practice
University of Brighton
School of Nursing and Midwifery
Westlain House
Village Way
Falmer, Brighton
BN1 9PH
Tel:
01273 644054
email: K.R.Hill@brighton.ac.uk
PLEASE KEEP A COPY OF THIS FORM FOR YOUR RECORDS
Form updated April 2011
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Module you wish to apply for
NA5106 (Level 5 Diploma) 
2
NA6156 (Level 6 Degree) 
Personal Details – PLEASE PRINT CLEARLY
If you change any of your details, especially your address it is essential you let us know
Title Mrs/Ms/Miss/Mr etc Male

Surname/family name (BLOCK CAPITALS)
Female

First name(s)
Previous surname, if changed, including maiden name
Date of birth
Student Number (if known)
Home address
Country of Birth
Have you lived and worked in the UK in the last 5 years?
Yes

No

Country of permanent residence
Post code
Email address (print clearly)
Nationality (n.b. you may be asked for further information regarding
your status)
First Language
Home telephone
NMC PIN & expiry date
Mobile telephone
3
Ethnic Origin (to be completed only if country of permanent residence is in the UK)
This information is not used in the selection process and is used for statistical purposes only. Ethnic origin is not the
same as nationality, place of birth or citizenship, but about your colour and broad ethnic group. Please describe as far
as possible your ethnic origin:
White
British
Irish
Other White
4
Black or Black British
11
12
19
Black Caribbean 21
Black African 22
Other Black 29
Asian or Asian British
Indian
Pakistani
Bangladeshi
Chinese
Other Asian
Mixed
31
32
33
34
39
White and Black Caribbean
White and Black African
White and Asian
Other mixed
Other Ethnic group
41
42
43
48
80
Disabilities and Special Needs
Please enter appropriate letter here

A – No disability
B – You have a social/communication impairment such as Asperger’s
syndrome/other autistic spectrum disorder
C – You are blind or have a serious visual impairment uncorrected by
glasses
D – You are deaf or have a serious hearing impairment
E – You have a long standing illness or health condition such as cancer,
HIV, diabetes, chronic heart disease, or epilepsy
F – You have a mental health condition, such as depression,
schizophrenia or anxiety disorder
Please record any special needs or support required on
an additional sheet if necessary. The university will use
this information to make appropriate arrangements to
support your studies at the university.
G – You have a specific learning difficulty such as dyslexia, dyspraxia
or AD(H)D
H – You have physical impairment or mobility issues, such as difficulty
using your arms or using a wheelchair or crutches
I – You have a disability, impairment or medical condition that is not
listed above
J – You have two or more impairments and/or disabling medical
conditions
PLEASE KEEP A COPY OF THIS FORM FOR YOUR RECORDS
Form updated April 2011
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Initial Professional Qualification
Applicants MUST enclose photocopy of initial professional qualification with completed application form.
Qualification
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Credit rating, if
applicable
Place of study
Date achieved
Post Registration Education
Please include details of all post registration courses or modules. If you are waiting for a result write PENDING in date column.
Applicants MUST enclose photocopies of post registration education with completed application form.
The information you give here will also be used to identify whether you would benefit from Study Skills training so please include
any Study Skills training you may have taken. Please note that you may be required to undertake study skills training first and then
resubmit your application.
Course/ Module title
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Credit rating, if
applicable
Place of study
Date achieved
What is your highest qualification?
This information is not used in the selection process and is used for statistical purposes only. Please state your highest
qualification, e.g. BSc or MSc
8
Current and Previous Employment Details
Post
Employer
Dates
Continue on separate sheet if necessary
PLEASE KEEP A COPY OF THIS FORM FOR YOUR RECORDS
Form updated April 2011
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References
Previous or present employer
Name:
Position:
Address:
Email address:
Telephone number:
Academic / character reference
(not a relative. Referee should have known you for a minimum of two years)
Name:
Position:
Address:
Email address:
Telephone number:
May we approach these referees before interview? Yes / No
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Fee Status
Fees will be paid by (one box MUST be ticked):
 Self funding student (who will be invoiced) The cost of the module for 2011-12 – £880, this can be paid in
instalments.
 Health Education Contract (previously PTD contract) – nb. We require your manager’s signature below and
section 11 must also be completed and stamped
Name of Trust: ……………………..……………..………………………………………….……
 Applicant’s employer (who will be invoiced). A Sponsor Identification Form must be completed (available on
http://www.brighton.ac.uk/snm/courses/post-reg/apply.php) nb. We also require your manager’s signature below
Name of organisation: …………………………………………………………………………….
 Other organisation with an agreed reciprocal arrangement with the School of Nursing & Midwifery nb. We require
your manager’s signature below
Name of organisation: ……………………………………………………………………………….
Signature of Manager ………………………………………..……………
Name ……………………………………………………….…
(Print clearly)
Date
Telephone ……………….…………………………..
PLEASE KEEP A COPY OF THIS FORM FOR YOUR RECORDS
Form updated April 2011
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11
Authorisation for Health Education Contract
If you ticked Health Education Contract (previously PTD contract) in section 10, this page MUST be stamped with the
SHA Health Education Contract stamp held by the following authorised signatories for your Trust. Please check the
following website for the most up to date signatories - http://www.inam.brighton.ac.uk/events/signatories.aspx:
SN271
SN220
SN201
SN272
SN040
SN284
TBC
SN206
SN273
SN275
SN013
SN210
SN274
SN270
SN155
SN039
SN231
SN276
Trust: please circle relevant code
Authorised Signatories
Ashford and St Peters NHS Trust
Brighton & Hove City Teaching PCT
Brighton & Sussex University Hospitals NHS Trust
East Kent Hospitals NHS Trust
East Sussex Healthcare NHS Trust (Merger of East
Sussex Hospitals NHS Trust, NHS East Sussex
Downs and Weald, NHS Hastings & Rother)
Eastern & Coastal Kent Community Health NHS Trust
Frimley Park NHS Foundation Trust
Maidstone & Tunbridge Wells NHS Trust
Medway NHS Foundation Trust
NHS Surrey
NHS West Sussex (Commissioning)
Queen Victoria Hospital NHS Trust
Royal Surrey County Hospital NHS Trust
South East Coast Ambulance Service NHS Trust
Surrey & Sussex Healthcare NHS Trust
Sussex Community NHS Trust (incorporating South
Downs Health NHS Trust)
Sussex Partnership NHS Foundation Trust
Western Sussex Hospitals NHS Trust
Carole Webster, Harriet Stephens
Marilyn Eveleigh, Pennie Rudd, Sarah Feeley
Jo Thomas
Helen O’Keefe
Gayle Clarke, Barbara Gosden, Angie Jarvis,
Shotham Kamath, Alison Ratcliff
Linda Tramontano
Clare Williams
Pam Bridger, Marian Palmer
Jennifer Hammond, Tracy Perkins, Ursula Clarke
Lorraine Demko
James Blakely, Liz Clay, Lizzie Izzard
Erika Thorne, Eve Savage
Louise Stead
Darren Palmer, Nick Sinclair
Arlene Stevens, Obi Maduako
Debera Robertson, John Krohne
Damien Cook
Cathy Stone, Christine Pearce, Sandra Ellard
BY STAMPING BELOW YOU ARE AGREEING TO: funding this application from the Health Education Contract
You are also agreeing to the Admissions Department transferring this funding authorisation to the Study Skills and IT
module if deemed necessary by the Admissions Tutor
SHA Health Education Contact Authorisation stamp (essential)
Signature:
Date:
PLEASE KEEP A COPY OF THIS FORM FOR YOUR RECORDS
Form updated April 2011
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Information in Support of Application
Include reasons for wishing to undertake the programme, what you expect to gain from the programme, what
contribution you feel you can make to the programme
PLEASE KEEP A COPY OF THIS FORM FOR YOUR RECORDS
Form updated April 2011
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Data Protection – Disclosure of Student Information (see guidance notes)
I confirm that the information I have given in this form is true, complete and accurate and no information requested or other material
information has been omitted I have read the notes of guidance, in particular those relating to this section and the withdrawal policy.
I understand what they say and agree to abide by the conditions set out there. I acknowledge that the information on this form will be
used in accordance with the Data Protection Act 1998 and will be used to form the basis of my student record. I give my consent to
the processing of my data by the university. I accept that if I do not fully comply with these requirements the university shall have the
right to cancel my application and I shall have no claim against the university in relation thereto.
I agree that the University of Brighton may disclose information regarding my student status, attendance and final
award to the Trust/organisation funding my study.
SIGNED BY APPLICANT ………………………………….......................................... Date......................................
SEND TO: Sam Taylor, School of Nursing and Midwifery, University of Brighton, Westlain
House, Village Way, Falmer, Brighton, BN1 9PH or FAX to: 01273 644010
PLEASE KEEP A COPY OF THIS FORM FOR YOUR RECORDS
Form updated April 2011
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