Multi-Professional Educator Course form

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Multi-Professional Educator Course form

South West London Training Hub

Which Borough do you work in

Full Name

Email Address

Job Role

Organisation

Line Managers Name

Line Managers Email

What type of students would you be an educator for following the programme (please select)

 Pre Registration Nurses

 Post Grad. Nurses/ advancing practice

 Pharmacists

 Physician Associates

 Nurse Associates

 First Contact Practitioners

 Healthcare Support Workers

 Occupational Therapists

 Other

Clear selection

If you answered other to Q7. Please specify any other student groups

What is your previous experience as an educator?

Is your workplace supportive of you becoming a Practice Educator and willing to host students in the future?

Yes

Maybe

Other:

Clear selection

Is your workplace a recognised learning environment?

(Workforce Training & Education Directorate - Quality approval process)

 Yes

 No

 In process of accreditation

Clear selection

Why do you wish to become a Primary Care Educator?

If you are unsure, then please answer unsure.

Have you had experience with Critical and Reflective writing? Where was this?

Consent obtained from your manager to ensure protected time is allocated for sessions.

Yes

Maybe

Clear selection

Declaration - By signing and submitting this form you confirm that

• You have your line manager and employer approval to undertake this course and

become an educator within your workplace

• That your workplace is an ALE or is in the process of applying to become an ALE

• That you are able to attend all 4 workshops face to face and undertake any associated pre reading or summative assessment work.

 I can confirm the above

 I cannot conform the above

Clear selection

Your signature (type your name)

I agree to be committed to use the sessions in a manner which is helpful and respectful to all parties.

Submit

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