Faculty of Health and Human Sciences

Faculty of Health and Human Sciences

BSc (Hons) Nursing (Adult)- CORNWALL

SELF DECLARATION – DIRECT ENTRY YEAR 2

PLEASE COMPLETE THIS FORM AND BRING IT WITH YOU TO THE INFORMATION/CARD COLLECTION SESSION ON:FRIDAY 09 SEPTEMBER 2016

NAME:...... Uni Number ………………… Nursing,Adult

(to include all forenames)

SITE: TruroCOHORT: September 2016COMMENCING:19/09/2016

Please answer the following questions as accurately as you can. If you answer a “Yes” to any of the following, you will be contacted by the Faculty of Health and Human Sciences Compliance Team for further information gathering.

Since completing your original application form:

1.Have you changed your name or are planning to change your name due to marriage, divorce, gender reassignment, other? YES / NO

If YES, give details and enclose any relevant documents

(i.e. marriage certificate, change of name deed)

......

2.Have you been convicted of any criminal offence, bound over, cautioned or have any court appearances pending? YES/NO

If Yes please give details

………………………………………………………………………………………………….

3.Have there been any changes to your Disclosure and Barring Service (DBS) record as this may jeopardise your ability to undertake the practice elements of the programme and professional registration. In addition if you have been involved in a formal interview with the Police or any other statutory authorities concerning protection of vulnerable adults or children you must disclose this information.

Non Disclosure

This also includes non-disclosure of events or circumstances that may materially affect your place on the programme or may affect the clinical placements we are able to obtain for you, and thus your ability to complete a programme of study. This is not an exclusive list but an example of issues that need to be reported is given below:

A family member who has received a custodial sentence
You are in receipt of a child protection plan
You are in receipt of a child in need plan
Your children are on the Child protection register

If you are unsure if this applies to you please contact the Field Lead during Welcome week. Non-disclosure of such events may mean you will be subject to Professional Issues Committee and may affect the offer of your place on the programme.

YES/NOIf Yes please give details

……………………………………………………………………………………………………………

4.Are you aware of any change in your health that has occurred since completing your Declaration of Health form? YES / NO

If YES, this information will be forwarded to the Occupational Health Department who may contact you regarding this disclosure.

…………………………………………………………………………………………

Does your new health condition/changes inyour health /or your treatment impact adversely upon your ability to undertake your placement or to undertake your studies?

YES / NO

5.RESIDENCY

5.aSince the age of 18, have you resided / travelled within any country that is outside of the UK, for more than 6 months (including any postings abroad with the Armed Forces)?

YES / NO

5bIf you answered yes to question 5a, please supply details of all such instances below. Continue on a separate sheet if required.

Dates: ……………………………………………………………………………………

Country: …………………………………………………………………………………

5cIf you answered YES to question 5a, have you provided your Certificate of Good Character?

YES / NO

6.INTERNATIONAL STUDENTS

6a For all International Student – have you resided in the UK for more than 6 months?

YES / NO

6bIf you answered YES to question 6a, have you had a UK Enhanced Disclosure and Barring Service check completed?

YES / NO

NOTE: If you answered No to question 6b, please contact the Programme Team or Compliance Team immediately as this may cause a delay in your placement.

7. Any other points you wish to mention?

......

8.ADDITIONAL INFORMATION REQUIRED - SPONSORED STUDENTS

Please indicate if you are being sponsored by a Trust or another organisation, i.e. you will continue to be employed/or you are to be employed by a Trust/organisationand will receive a salary whilst you undertake your nurse training.

If you are in the process of/or are awaiting a trust interview please answer “pending” to the above question and let us know the name of the Trust concerned. Please let us know the outcome as soon as possible.

YESNOPENDING

If you have answered “Yes” or “Pending” to the above question please indicate the name of the seconding Trust/organisation and provide us with evidence of your sponsorship.

………………………………………………………………………………………………

Please provide the name and contact details of the Trust representative who will be providing you with support throughout the programme.

Name:………………………………………………Telephone No:…………………………………

Email address:………………………………………………………………………………………………

DECLARATION

I understand that failure to disclose any information requested above could result in my application being reviewed by the Professional Issues Committee procedures and possible withdrawal from the programme.

Signed: ……………………………………………………… Date ……………………………………...

Direct Entry Year 2Self DeclarationAdult S15CornwallPage 1 of 4