- Staffordshire Training Hub

Staffordshire Nurse Roots Student Nurse Placements Expression of Interest Form

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Thank you for expressing an interest in a placement with the Staffordshire Training Hubs [STH] Nurse Roots Hybrid Placement Programme. To enable us to review your placement request, please complete all required fields as thoroughly as possible. Unfortunately, incomplete forms cannot be accepted and will therefore not be considered. Once you have submitted your completed form, the Nurse Roots Placement Team will review the information provided and contact you regarding your request. If you have any questions, please contact the team directly at traininghub@gpfirst.net. We look forward to receiving your expression of interest information.

Important: In addition to completing the STH Expression of Interest Form below, it is essential that you also inform your university placement team of your interest in a Nurse Roots Placement as part of the placement allocation process. Please be aware that demand for these placements is high, and places are limited. Failure to notify your university placement team may delay or prevent your placement from being allocated.

First Name:*

Surname:*

Your university email address:*
Email address Confirm email address

Phone Number:

Name of University*

Keele University

University of Staffordshire

Wolverhampton University

Derby University

Other

Placement Team Contact Email Address:*

Branch of Nursing:*
Adult
Child
Mental Health
Learning Disabilities

Current Programme:*
MSc
MSCi
BSc

Duration of programme:*
2 years
3 years
4 years

Which year of study are you currently on?*
Year 1
Year 2
Year 3
Year 4

Please outline what part you are currently studying:*

Part 2

Part 3

Other

Please outline the details of the placement you are requesting including (Dates, duration, clinical hours & hours of reflection/Pad time)*

Is this placement an assessment or non assessment [elective]?*

Assessment

Non Assessment Elective – Part 2

Non Assessment Elective – Part 3

Please specify weekly placement hours required.*

37.5 Hrs with 2.5 Hrs reflection

37.5 Hrs with 3.5 Hrs reflection

40.0 Hrs with 2.5 Hrs reflection

40.0 Hrs with 3.5 Hrs reflection

Other

Reason for wanting a Primary Care placement:*

Have you previously had a Primary Care placement?*

Yes

No

If yes, please provide name of practice and a brief summary of your experience.

Have you got access to a car/reliable public transport and willing to travel between clinical, education and insight sessions?*

Yes

No

Can you commit to a Monday – Saturday working week between the hours of 0800 – 1800?*

Yes

No

Have you read the information about the expectations and commitment of the hybrid placement model and eligibility criteria?*

Yes

No

Preparing for your placement starts before your first day. The information below will help you understand what to expect, how the Nurse Roots model operates, and what you need to do before your placement begins. Please confirm that you have read and agree to the below.

I confirm acceptance of the placement and will return all requested documentation no later than three weeks before my placement begins. Due to the high demand for Nurse Roots placements and the preparation required by placement providers, I understand that failure to do so may result in my place being offered to another student.*

Yes

No

I understand that the hybrid Nurse Roots model involves travel between multiple learning environments. I confirm that I have suitable transport arrangements to enable my attendance to all timetabled sessions for the duration of the placement period.*

Yes

No

I am aware that all education, induction and clinical skills sessions are held in Stafford.*

Yes

No

I am aware that insight sessions take place across Stafford, Cannock, North Staffordshire and Stoke-on-Trent, typically on Thursdays, Fridays and some Saturdays and can commit to attendance of these where timetabled.*

Yes

No

I understand that practice placement days are usually Monday to Wednesday and cannot routinely be changed.*

Yes

No

I confirm that I am happy to complete and present a Quality Improvement (QI) project, and understand that this contributes towards my placement hours.*

Yes

No

I understand that my weekly hours will vary due to the hybrid nature of the programme; but my overall placement hours will meet the required minimum.*

Yes

No

I understand that additional ‘make-up’ placement hours are not routinely available but will discuss any concerns about my placement hours with Staffordshire Training Hub as early as possible.*

Yes

No

By confirming my attendance on the programme, I agree to complete all required programme components and allocated placement hours. If I undertake an elective placement, I agree to complete all allocated placement hours, regardless of whether they are required as part of my academic programme.*

Yes

No

IMPORTANT INFORMATION FOR FINAL YEAR ELECTIVE PLACEMENT HOURS – Due to the nature of the hybrid model and the involvement of multiple supporting professionals, agencies, and practices, students undertaking an elective placement are required to complete all allocated placement hours, regardless of whether these hours are required as part of the academic programme. If you are unable or unwilling to commit to completing all allocated placement hours, including any hours that exceed your total elective and/or programme hours, you must inform your placement team as soon as possible. Please note that if you are unable to commit to completing all allocated placement hours, we will be unable to support your elective placement.

I understand that I may be allocated to more than one General Practice within a Primary Care Network (PCN) and will ensure that I can attend all allocated placement sites.*

Yes

No

Any other comments:

Human verification