Preparatory Form for External UK Elective Placements

To be completed by students undertaking elective placements outside the area covered by the Health Education England (Yorkshire and Humber) Learning & Development Agreements

This checklist has been devised to help you with the arrangements for your elective, a summary is included on page 5 to assist you with the documentary process. As soon as you have provisional agreement from a placement provider that they will offer you a placement, please complete and sign Section A and copy this to your contact in the Allocations Team (details on page 5). We will then contact your placement to request the signing of a legal agreement. You should retain the form and work through the issues and requirements until you have completed all sections fully. At this point submit a complete version to your contact in the Allocations Teamno later than a month before you travel.

Please note that the Department can refuse to allow you undertake this elective placement if you fail to meet the deadlines for submission of elective documentation.

SECTION A

1. Student Name and Cohort:
Placement Dates:
these dates form part of the legal agreement
so must be accurate / ……………………………………………………
……………………………………………………
2. Student email address:please note we can only
correspond via your university email account / @york.ac.uk
3. Programme of Study: / Nursing Midwifery
4. Understanding eligibility risk: Nursing Students Only / A nursing student whose elective placement becomes summative (requiring formal assessment) will not be permitted to undertake aplacement in this category. Students MUST be aware that any costs incurred in developingplanning this experience are at their own risk.
Signature: ……………………. Date: ………….
5. Personal Supervisor’s agreement:this is your University Personal Supervisor, / I confirm that this is an appropriate elective proposal and that I support the development of this experience for this student.
Signature: ………………….. Date: ………….
Print Name:………………………………………
6. Has the placement provider provisionally
agreed to offer you a placement?
NB this should be agreed before submission
of section A of this form /
Yes
7. Placement Contact Details:
Essential to provide accurate email address / Name:
Job Title:
Tel Number:
Email Address:
8. Full Placement Details:
Name of Placement / Unit:
Hospital (if applicable):
Full Trust or Organisation Name:
(essential as this forms part of the agreement)
Address line 1:
Address line 2:
Address line 3:
Address line 4:
Postcode:
9. Practice Hours
You are required to work the number of
practice hours stated on your programme
course plan. Please sign to confirm you
have discussed this requirement with your
placement contact and they are able to
offer you the number of hours needed. / Student Signature:

IMPORTANT – YOUR RESPONSIBILITIES - PLEASE READ CAREFULLY:-

The opportunity for students to explore elective options further afield is one which the Department would like to see continue but is an area which can be resource intensive. In order to safeguard the continuance of these opportunities, we need to ensure that students lead the process proactively.

The organisation of elective placements outside of the Yorkshire & Humber region is your sole responsibility. You must ensure that you check with your placement provider as to what documentation they require from you at an early stage. This should allow you sufficient time to obtain and supply the evidence they may request e.g repeat DBS (formerly known as CRB checks), health clearance etc.

It is essential that you keep in touch with your contact in the Allocations Team regularly to check on the progress of the signing of the legal agreement. Although you will be advised via email when the agreement is signed and received, you will not be routinely contacted to remind you that this is outstanding. You will be responsible for chasing up non-communication from your placement contact and for ensuring all documentation is received into the department prior to placement commencement.

You are required to submit the remainder of this form (Section B) at least one month prior to placement. You must not leave any sections blank or with queries noted. You are responsible for doing this within the timescales required, therefore, please diarise a reminder to yourself.

Once the legal agreement is signed and received and Section B of this form is submitted satisfactorily, you will be issued with a letter confirming you have clearance to attend this external placement. Until all of these elements are in place you must consider your plans provisional and take the personal risk associated with any costs incurred. You must not attend placement without this clearance letter. If you do so, your failure to adhere to requirements may be noted on your End of Programme Reference.

Please be aware that the department reserves the right to prevent or withdraw permission for students to attend external elective placements. This can be due to academic/programme issues or if the department has serious concerns regarding the safety of the student in the proposed area.

Please sign and date below to confirm you have read and understood this information and accept your responsibilities in relation to the above requirements.

SIGNATURE ………………………………………………………………………….. DATE ………………………

SECTION B

STUDENT NAME:______

PLACEMENT ATTENDING: ______

1. Cost: You need to make a budget for:
Accommodation
Travel Arrangements
Living Costs
Other
This list is a guide to costs, you should
add other items in as you plan your
placement. / Done _____
Done _____
Done _____
Done _____
2. Have you arranged accommodation
during placement? If yes, please give
summary details / Yes No
Details:
3. Does the placement want a new
Disclosure & Barring Service check
(formerlyCRB) check?
DBS clearance obtained
(if you require a new check for your
placement please contact the admissions
staff, Tel: 01904 321310 / Yes No
Yes
4. Placement insurance – liability and
professional indemnity cover
Please confirm that you have
taken out membership of a professional
union (e.g. RCN / RCM / Unison)
Please confirm that this provides you
with professional indemnity cover to
practice in your elective placement
organisation / Union:
Membership No:
Student Signature:
Date:
YES NO
5. Midwifery students only:
Has this offer been made on an
observational only basis?
If Yes, please sign statement below:-
I understand that this elective placement
is for observational purposes only and
that I will not be undertaking practice. / YES NO
Student Signature:
Date:
6. Please record your contact details while
you are on your elective for use by the
University in the event of an emergency.
7. I agree to the Department confirming to
the placement provider that I fulfilled
the screening requirements for entry to
the course in relation toDBS check,
health assessment and references / Student Signature:
Date:
8. I understand I may be required to share
my immunisation record with the
placement provider. / Student Signature:
Date:
9. I understand that the placement
provider has the right to exclude me from
practice if my health or behaviour is
deemed to constitute a risk to myself,
patients or other staff. / Student Signature:
Date:
10. I understand that, whilst on placement,
I will be subject to the policies and
protocols of my placement provider. / Student Signature:
Date:
11. I confirm that I will notify the University
if the arrangements for my placement
are different from what has been
arranged or if I have any concerns about
the activities I am asked to do that
cannot be resolved by discussion with
my placement provider. / Student Signature:
Date:
12. I understand that it is my responsibility
to advise my placement provider of any
adjustments that need to be made to
compensate for any health or disability
issue to allow me to undertake my
placement. / Student Signature:
Date:

If you need advice from the Department while you are on your elective placement, you can either contact your personal supervisor or:

Vanessa Taylor, Deputy Head of Nursing, Midwifery & Professional Programmes

l: 01904 321659

Julie Platts, Student Allocations Manager:

tel: 01904 321311

Rob Allison, BSc Nursing Programme Leader:

tel: 01904 321689

Helen Joyce, BA Midwifery Practice Programme Leader:

tel: 01904 321824

This form should be fully completed before you commence your placement. A final copy must be left with your contact in the Allocations Team (at least one month before you go) and you should retain a copy for your own records.

Please do not submit this form with any omissions or queries – it must be completed in it’s entirety (up to and including this page) before submission.

CHECKLIST / TIMESCALES to assist you with the documentary process

a)Submit Section A of this form by the timescales given in your cohort specific Elective Guidelines

b)Contact your Allocations Team contact* four weeks after submission and fortnightly thereafter to enquire about the progress of the legal agreement (unless advised otherwise).

c)Chase up your placement contact if they have failed to respond.

d)Continue to work through Section B, obtaining all the necessary information to complete this section fully.

e)You will receive an email to confirm when the legal agreement is received.

f)Submit Section B to your Allocations Team contact (again as soon as completed but not later than one month prior to travel.

g)Ensure you are in receipt of your Clearance to Attend Elective Placement letter (from your Allocations Team contact) before you commence placement.

*Allocations Team Contacts:-

Adult Nursing Julie Platts – email or tel 01904 321311

Mental Health NursingSue Maude – email or tel 01904 321316

Child NursingSue Maude – email or tel 01904 321316

Learning Disability NursingJulie Platts – email or tel 01904 321311

MidwiferySarah Wooffitt – email or tel 01904 321316

Voluntary Report on your Elective Placement

We hope your Elective Placement turned out to be a great experience. If you are happy to share a few details about your trip it could be helpful to future students when planning theirs and may well inspire them too! With your permission, we may publish these reports on the student intranet and may also use your story as an article in the Department newsletter, Megaphone.

Please retain this section of the form for voluntary completion after your placement. When you have completed the details please return to Julie Platts, Student Allocations Manager, Seebohm Rowntree Building Area 5, Department of Health Sciences, University of York YO10 5DD. Or send as an attachment to .

  1. Your name:
  1. The dates of your placement:
  1. Where did you spend your placement?
  1. How did you go about deciding where to spend your placement? (e.g., was this at an established centre or did you look further afield?)
  1. What was your experience of planning your trip (e.g. if abroad, how much research was involved?)
  1. Please write a description of your placement, including your expectations and actual experience (feel free to continue on another page and to include any tips you’d like to share).
  1. Is there anything specific you would like to draw to the attention of a student planning to pursue a similar experience?
  1. As you will be sharing specific details of your actual placement, please ensure you obtain the agreement of your placement contact that the content is acceptable for publication. If you are also supplying photographs, please ensure you have permission from anyone pictured in them.
  1. Finally, would you be happy to be contacted directly by students to discuss your elective after you have completed your course? If so, please provide an email and postal address which would be retained by the Allocations Office for passing to interested students. Please note these details will not be published on the intranet.
  1. Please sign below to acknowledge that you agree to the Department publishing your story and that you have the agreement of your placement contact to share this information.

Signature………………………………… . NAME…………………………………………….

Date……………………………………….

1 J Platts July 17