Assignment Upgrade Form – Bank Only

(This form should be used for all bank only flexible workers requesting an upgrade from e.g. CSW to CSWH or RN to NTL etc.)

Flexible Worker Information
Name of Flexible Worker
Date of Birth or ESR Assignment Number
Current Assignment code(s)
Requested Assignment code(s)
Authorising Manager Information
Authorising Manager (print name)
Trust Employed By
Position In Trust and ward/ unit
Telephone number
I confirm that I have appropriate experience in the area in which I am authorising this Flexible Worker to have an additional assignment code(s)
I confirm that I understand that by authorising this amendment that this Flexible Worker will be able to work at this Trust and locations at this assignment.
I confirm that this Flexible Worker is competent to work at this assignment code and that they have provided the following evidence (copies enclosed where applicable)
CSW to CSWH (tick appropriate box) / Yes / No
1. NVQ Level 3 in Health Studies
2. Competence in undertaking procedures such as venepuncture, recording ECGs, IV cannulation, applying basic dressings
RN to NTL (tick appropriate box)
1. Post registration qualification in specialty
2. Teaching and assessing qualification and skills
3. Experience as preceptor and /or clinical supervisor
4. Able to provide clinical and managerial supervision to nursing and support staff in the absence of the Senior Nurse and as part of the MDT
5. At least 2 years’ experience as a Registered Nurse in the specialty
Signature of Authorising Trust Manager (can be accepted without if completed form sent from manager’s trust email address)
Date
NHS Professionals Information
Number of shifts worked by Flexible Worker in above ward/ unit in previous 6 months
Confirmed by Trust Liaison Coordinator (print name and date)
Complaint history reviewed on CIMS / Acceptable/ not acceptable (delete)
Recruitment file reviewed on Cavetab / Acceptable/ not acceptable (delete)
Confirmed by Clinical Governance authoriser (print name and date)
Authorisation for Upgrade
Upgrade authorised (yes/no)
Confirmed by Clinical Governance authoriser (print name and date)

Bank only CCS upgrade form

CG V2

June 2011