Return to Practice Programme Application Form
Please complete this form in BLOCK CAPITALS.
Personal DetailsSurname: / First Name:
Address for Correspondence:
Contact No: / DoB:
Email Address:
NMBI Registration Details
NMBI PIN:
Active Registration: enclose a copy of your NMBI registration with this application
Inactive Registration: see page 6 of NMBI Standards and Requirements
See more at http://www.nmbi.ie/Registration/the-Register-and-Divisions#sthash.lFXN6312.dpuf
Please indicate which registrations you hold with NMBI and date of registration
Designation Titles / Abbreviation / / Registration DateRegistered General Nurse / RGN
Registered Midwife / RM
Registered Children's Nurse / RCN
Registered Psychiatric Nurse / RPN
Registered Nurse Intellectual Disability / RNID
Registered Public Health Nurse / RPHN
Registered Nurse Tutor / RNT
Registered Nurse Prescriber / RNP
Registered Advanced Nurse Practitioner / RANP
Registered Advanced Midwife Practitioner / RAMP
If you require extra space for any of the following section, please use a separate A4 sheets and clearly indicate which section you are completing.
Education & Training HistoryPlease include All Nursing/Midwifery Registration Courses and
all Other Relevant Training/Education
Name & Address of Nursing School, College, Centre of Further / Higher Education / From
mm/yyyy / To
mm/yyyy / Qualification Achieved
Have you previously completed a Return to Practice Programme?
Yes (insert date completed) / No
If you have answered yes, did you take up employment following completion of the programme, include location and dates as appropriate.
Please give detail as to why you wish to undertake the Return to Practice Programme and what benefit it will be to you?
Please indicate your preferred location for undertaking the Return to Practice Programme
HSE South East (Carlow, Kilkenny, Waterford, Wexford & Sth Tipperary)
Centre of Nursing & Midwifery Education, Waterford
Closing Date for receipt of EOI/application forms: March, 2018 / May 2018
HSE Dublin North
Centre of Nursing & Midwifery Education, Connolly/Mater
Closing Date for receipt of EOI/application forms: 7th February 2018 / Summer 2018
HSE Dublin Mid Leinster
Centre for Learning and Development, St. James's Hospital, Dublin 8
Closing Date for receipt of EOI/application forms: Mid April 2018 / June 2018
Midwifery Programme
Closing Date for receipt of EOI/application forms: 16th March 2018 / 11th June 2018
Children’s Programme
Closing Date for receipt of EOI/application forms: 29th June 2018 / 20th August, 2018
Employment History
Please commence with most recent employer.
From:
mm/yyyy / To:
mm/yyyy / Position Held: / Name & Address of Employer: / Reason for Leaving:
Please give any further information that may be relevant to your application.
References
One reference should be from current or most recent employer.
Name: / Name:
Address: / Address:
Title: / Title:
Declaration
I confirm that the above information is true and correct, and understand that any misrepresentation will invalidate my application.
If accepted onto the programme I agree to;
· Provide a photocopy of my NMBI registration or letter directing me to undertake a Return to Practice programme as a prerequisite to registration.
· Complete Garda Vetting procedures and complete a Garda Clearance form
· Complete a Pre-Placement Health Declaration Form and provide information in respect of my immunization status from my GP.
· I declare that I am not the subject of any investigation by the Nursing/Midwifery Registration Body in any jurisdiction with regard to my Nursing Practice or conduct as a Nurse or Midwife. I have not been censored by or suspended from registration by any Nursing/Midwifery Registration Body in any jurisdiction in the last ten years nor am I subject to any current suspension/censure.
Signature : / Date:
Application No: / For Administrative Purposes only.
Date Received:
Please return completed signed application form to or
Nursing Midwifery Planning & Development, HSE Dublin North, Swords Business Campus, Balheary Road, Swords, Co Dublin
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