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University Use Only
UNDERGRADUATE NURSING STUDIES: DIRECT APPLICATION FORM
The categories of applicants listed below who are seeking admission to the University, are required to apply directly to
DCU using this form. Please indicate with a tick () the category under which you are applying.
Certificate in Nurse / Midwife Prescribing. For further information on entry requirements and programme
details, please see www.dcu.ie. Closing date for applications is 30th July.
Please ensure all supporting documentation listed on Page 7 is submitted along with your form.
Please return together with the necessary supporting documentation and the appropriate (non-refundable) application
fee of €35 by cheque, postal order or bankdraft to the Admissions Office, Registry, Dublin City University, Dublin 9.
N.B. All applications, for Nursing programmes other than those indicated above MUST be made through the CAO,
Central Applications Office, Tower House, Eglinton Street, Galway, Ireland. (Telephone: +353-(0)91-509 800;
Fax: +353-(0)91-562 344; Web: http://www.cao.ie)
Please complete this form in BLOCK LETTERS using BLACK ink. All questions must be answered. DO NOT leave
blanks.
BIOGRAPHICAL INFORMATION:
NAME :
Surname
First Name(s)
NAME AS ON BIRTH CERTIFICATE (if different from above):
Surname
DATE OF BIRTH:
___ / ___ / ___
CITIZENSHIP: ___________________________
First Name(s)
GENDER:
Male
Female
COUNTRY OF BIRTH: ___________________________
PPS NUMBER (If applicable) _______________
COUNTRIES OF RESIDENCE
Please indicate the countries in which you were ordinarily resident for the 5 years preceding the date of this application:
Country:
From: MM/YY
To: MM/YY
ADDRESS FOR CORRESPONDENCE:
(Please notify us if your address changes.)
OTHER CONTACT DETAILS:
Home Telephone:
Mobile Telephone:
Work Telephone:
Email Address (Print clearly):
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TITLE(S) OF THE PROGRAMME(S) FOR WHICH YOU ARE APPLYING FOR ADMISSION IN ORDER OF
PREFERENCE (you can apply for up to 3 programmes on this application form):
1st Preference:
Title of Programme: _________________________________________________________
Full-time
Part-time
Modular Degree
Undergraduate
Degree
Diploma
2nd Preference:
Title of Programme: _________________________________________________________
Certificate
Access/Qualifier
Full-time
Part-time
Undergraduate
Degree
Diploma
3rd Preference:
Title of Programme: _________________________________________________________
Undergraduate
Full-time
Part-time
Degree
Diploma
Modular Degree
Certificate
Access/Qualifier
Modular Degree
Certificate
Access/Qualifier
Please note that not all programmes are available on a part-time basis.
WHERE DID YOU HEAR ABOUT OUR PROGRAMMES?
Radio Advertisement
Advertisement on Public
Transport
Education Fair
Word of Mouth
Newspaper/Magazine
Advertisement
School Poster
Cinema Advertisement
Career Guidance/Teacher
Other – please specify:
International Agent
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SECONDARY SCHOOL EDUCATION
Name and Full Postal Address
Dates of Attendance
(i)
from
to
FINAL SCHOOL LEAVING EXAMINATION RECORD
(Please ensure that an official certificate of results is included. A certified translation into English must be provided
for results from non-English speaking countries):
TITLE OF EXAMINATION
YEAR OF EXAMINATION
SUBJECTS
Level of Exam
Grade Or Mark
Level Of Exam
Grade Or Mark
ENGLISH LANGUAGE COMPETENCY (for non-native speakers of the English language only):
Examining Body e.g. IELTS,
TOEFL, Cambridge Proficiency
* Cert should be included
Actual or Expected
Completion Date
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DETAILS OF FURTHER EDUCATION / PROFESSIONAL EDUCATION (IF ANY)
(Transcripts to be included)
In chronological order moving from left to right:
Institution Attended
Period of Attendance
Name of Programme
Duration of Programme
Full-Time or Part-time
Title of Award (if any)
Name of Awarding Body
Have you completed the
programme?
Yes
No
Yes
No
If ‘No’ please indicate

Period Completed to Date:

Date on which Final Results
will be available:
Level/Class of Award
Main subject areas studied, with
marks or grades obtained;
continue on a separate sheet if
necessary.
DETAILS OF OTHER ACADEMIC, PROFESSIONAL DISTINCTIONS AND CONTINUING EDUCATION:
(if there is insufficient space please use a separate sheet and enclose with application)
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EMPLOYMENT SINCE LEAVING FULL-TIME EDUCATION IN CHRONOLOGICAL ORDER BEGINNING WITH THE
MOST RECENT:
Name and Address of Employer
Capacity in which you were employed
From
Dates
To
GENERAL INFORMATION
Why did you choose the programme that you are applying for, and which type of career or occupation do you hope to
pursue as a result of taking this programme?
Have you any work experience in this area? If so, give brief details.
What attributes or characteristics do you feel you have which make you particularly suitable for this career or
occupation?
Other information deemed relevant to the application.
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It is not a mandatory requirement for an applicant to disclose their disability if they do not wish to do so. However, where a
student chooses to disclose their disability, it is advisable to notify the DCU Disability Service on acceptance of a
programme place so as to enable the Disability Service to provide reasonable supports to the student during their time at
DCU.
No applicant will be disadvantaged as a result of disclosing information pertaining to a Medical Condition/Disability.
Intending applicants may contact the disability service on tel: +353 (01) 7005927 or email: disability.service@dcu.ie
for further information.
REFEREE CONTACT DETAILS:
(The Registry will assume permission to contact referees unless an applicant has stated otherwise.)
Name of Referee
Name of Referee
Position in organisation
Position in organisation
Address
Address
Tel.No.
Tel.No.
DECLARATION:
I certify that the information given in this application is correct and I hereby undertake, if admitted as a student member
of Dublin City University, to observe and comply with all the regulations of the University.
*Signature of Applicant: _______________________
(Mandatory)
Date: ______________________________________
One passport photograph
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FINAL REMINDER CHECKLIST:
1)
Certified copies of original transcripts of results
 Please do not send originals
 Copies must be stamped by conferring university
2)
One passport Photograph
3)
Application fee
(€35 for EU applicants/€60 for non-EU applicants)
4)
Photocopy of Birth Certificate
 Please do not send originals
5)
Signed declaration on page 6
Non-national English speaking countries (where applicable)
6)
Evidence of competency in the English language
7)
Certified translation into English of results/qualifications
Course requirements: Certificate in Nurse / Midwife Prescribing
1)
A Signed Site Declaration Form (Apendix one to this form)
2)
Original or certified true copies of your current 2011 Registration certificate
with an Bord Altranais for all of your nursing qualifications. You are required to
send the registration letter from an Bord Altranais and your PIN.
3)
Written evidence from your employer that you have completed a minimum of three
Years post registration nursing experience and that you have worked in your area
of practice for at least one year full time equivalent.
4)
A typed statement - on a separate page – of your ability to use information
technology (200 words Maximum)
Please return the completed application form, ensuring that you have attached All supporting documentation and the
appropriate (non-refundable) application fee (€35 for EU applicants/€60 for non-EU applicants) by cheque, postal order
or bankdraft to:
Non-EU Students only: Non-EU Undergraduate Admissions, International Office, Dublin City University, Dublin 9,
Ireland.
All others: Admissions, Registry, Dublin City University, Dublin 9.
Telephone: +353-(0)1-700 5338;
Fax: +353-(0)1-700 5504;
E-mail: registry@dcu.ie; Web: http://www.dcu.ie/registry/applications.shtml
Thank you for your application
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Appendix 1: Site Declaration Form
Nurse and Midwife Medicinal Product Prescribing
Site Declaration Form 2011
Essential Criteria for Site Selection
This Site Declaration Form is to be completed on behalf of the Health Service Provider by the Director of
Nursing/Midwifery/Public Health Nursing or relevant nurse and midwife manager and submitted with the college
application to Dublin City University.
Please note: For students employed in the voluntary and statutory services of the HSE a copy of this form will be
sent to the office of the Nursing and Midwifery Services Director, Health Service Executive
Criteria
Safe Management
Do you have in place an Organisational Policy for Nurse and
Midwife Medicinal Product Prescribing (or will a policy be in place
by the time the nurse or midwife completes the education
programme)?
Can you demonstrate an ability to safely manage and quality assure
prescribing practices?
Do you have risk management systems in place?
If yes, is there a process for:




Yes
No
Comment/Evidence
Adverse event reporting?
Incident reporting?
Reporting of near misses?
Reporting of medication errors?
Practice and Education Development
Do you have in place appropriate mentoring arrangements with a
named medical mentor? (please identify name of mentor).
Do you have in place robust and agreed collaborative practice
arrangements? (if not already existing, will it be in place by the time
the nurse or midwife completes the education programme?)
Have you identified a named medical practitioner(s)/mentor who has
agreed to develop and agree the collaborative practice arrangements?
Can you confirm that the name of the nurse or midwife applying for
the Certificate in Nurse/Midwife Prescribing has current active
(2011) registration with An Bord Altranais
Do you have in place a commitment to continuing education for staff
supporting the prescribing initiative?
For HSE statutory and voluntary services will you have in place a
sponsorship agreement at local (service) level setting out the
arrangements for study leave and financial support for the candidate
Registered Nurse Prescriber?
Health Service Provider
Do you have in place or have access to a Drugs and Therapeutics
Committee? (If No, please describe how this will be achieved?).
Do you have in place local arrangements to oversee the introduction
of a new practice in prescribing and ensure local evaluation?
Do you have in place a named individual (Prescribing Site
Coordinator) delegated by the Director of Nursing to have
responsibility for the initiative locally and for liaison with the
educational provider? For students employed in the voluntary and
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statutory services of the HSE the Prescribing Site Coordinator will
also liaise with Office of the Nursing Service Director (please supply
name of prescribing Site Coordinator).
Have you established the clinical indemnity arrangements for
nurse/midwife prescribing? (please note the Clinical Indemnity
Scheme managed by the State Claims Agency covers employees of
the voluntary and statutory services of the HSE)
Criteria
Do you have in place a firm commitment by the
hospital/organisation board or Chief Executive Officer or Medical
Director/Chairman of Medical Board to support the introduction of
this prescribing initiative?

Yes
No
Comment/Evidence
For students employed in the HSE voluntary and statutory
services (only): will your organisation comply with and ensure
data input for Nurse and Midwife Prescribing Data Collection
System?

For all other health service providers – can you confirm that you
will have a process for monitoring prescribing activity?
For students employed in the voluntary and statutory services (only)
can you confirm that the Registered Nurse Prescriber will have
access to a computer, email and internet for data input to the Nurse
and Midwife Prescribing Data Collection System?
Will your organisation share details of the Registered Nurse
Prescriber’s scope of practice and prescriptive authority with
relevant health professionals?
Audit and Evaluation
Do you have in place or are you planning to put in place a
mechanism to audit the introduction of nurse/midwife prescribing
practices?
Note: It is a requirement of An Bord Altranais that clinical placements for the Certificate in Nurse/Midwife
Prescribing are based in health care institutions which are audited and approved by the education programme team
and satisfy An Bord Altranais Requirements and Standards for Education Programmes for Nurses and Midwives
with Prescriptive Authority. Failure to satisfy these requirements and standards may result in a delay to a student’s
progress through the programme until outstanding issues are resolved.
Printed name of the Director of
Nursing/Midwifery/Public Health
Nursing/or relevant Nurse/Midwife
manager:
Name of health service provider:
Telephone number:
Email:
Printed name of the Medical
Practitioner/Mentor
Name of health service
provider:
Telephone number:
Email:
Signed by the Director of Nursing/Midwifery/Public Health Nursing/or relevant Nurse/Midwife manager:
_________________________________________________________________________________________________
Date:
_________________________
Signed by the Medical Practitioner/Mentor:
___________________________________________________________________________________________
Date:
_______________________
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Please check the following:
1.
The form is fully completed. Incomplete forms will not be considered
2.
Your mentor is aware of the mentorship requirements as set out in this form. The mentor can contact the programme co-ordinator, Mary
Kelly at telephone: 01 7008530 or email: mary.t.kelly@dcu.ie for further information prior to signing the form
3.
The name you give on the application form is the name by which you are registered with An Bord Altranais and which will appear on
your student ID card, college records and parchment.
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