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Page 1: sohsc.tees.ac.uk · Web viewContents Practice Placement Form2 Learning outcomes 3-4 Objective sheets for first week5-8 Half Way Visit Guidance9 Half way formative assessment form10-19

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Page 2: sohsc.tees.ac.uk · Web viewContents Practice Placement Form2 Learning outcomes 3-4 Objective sheets for first week5-8 Half Way Visit Guidance9 Half way formative assessment form10-19

Contents

Practice Placement Form 2

Learning outcomes 3-4

Objective sheets for first week 5-8

Half Way Visit Guidance 9

Half way formative assessment form 10-19

Half way visit form 20

Objective sheets for last two weeks 21-24

Assessing the students communication 25and inter-personal skills

Feedback tool 26-28

Final assessment report form 29 – 36

Timesheet 37-39

Welcome to your practice placement one work book. This is designed to guide you through the stages of the placement and incorporates all the relevant documentation required for your placement. For additional information please refer to the Practice Placement Handbook.

Please ensure you contact the academic allocated to your placement to arrange a half way tripartite meeting during your first week of placement.

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PRACTICE PLACEMENT 4 ASSESSMENT FORM

PgDip/MSc Occupational Therapy

Name of Student

Name of Practice Placement Educator

Address of Practice Placement

Speciality

Dates of Practice Placement to

Number of Hours Completed

Reasons for Absence

During the first half of the placement one objective sheet should be completed per week, be used to give direction with supervision and written in conjunction with the learning outcomes shown over the page.

A half way report is written at the half way point and should give the student an understanding of their performance to date and identify their strengths and development needs. Each learning outcome has a comment box which when completed should help the student to understand what they need to do to complete the placement successfully.

During the latter half of the placement one objective sheet should be completed per week, be used to give direction with supervision and written in conjunction with the learning outcomes shown over the page.

It is important to obtain service users and carers views of the students’ performance on placement. During the placement the educator should use the feedback tool to gain information from service users/carers regarding the student’s communication and interpersonal skills which can then then contribute to the student’s final report.

The final written report should give a clear indication the student of their performance. A result of ‘pass’ or ‘refer’ should be awarded for each learning outcome. In the comments box please provide feedback to assist the student in their understanding of their strengths and areas of development which may need to be addressed in the rest of the placements

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Learning outcomes for this placement are as follows:

Able to demonstrate the ability to practise as an autonomous professional, exercising their own professional judgement under the direction of a placement supervisor.

Able to demonstrate effective self management of work load and resources.

Able to demonstrate the ability to work in partnership with other staff, service users and carers.

Able to demonstrate effective and appropriate communication skills including communication and information technologies.

Able to demonstrate knowledge of when it is appropriate to share information to safeguard service users or the wider public.

Able to demonstrate the ability to select and use appropriate assessment techniques.

Able to demonstrate the use of reasoning and problem-solving skills to determine appropriate actions.

Able to analyse research and other evidence to inform their own practice.

Able to draw on appropriate knowledge and skills in order to make professional Judgements.

Able to formulate specific and appropriate management plans including the setting of timescales.

Able to demonstrate appropriate interventions or other actions safely and skilfully.

Able to demonstrate the ability to keep accurate comprehensive and comprehensible records in accordance with legislation and guidelines.

Able to Monitor and review the ongoing effectiveness of planned activity and modify it accordingly.

Able to demonstrate the ability to reflect on and review practice.

Able to apply the theoretical concepts underpinning occupational therapy.

Able to know how professional principles are expressed and translated into action through a number of different approaches to practice.

Able to demonstrate the need to establish and maintain a safe practice environment.

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Able to understand the importance of participation in supervision and mentoring

Where possible please limit learning objectives to 6 per week.

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PgDip/MSc Occupational TherapyWEEKLY OBJECTIVES AND SUPERVISION FORM

(Practice placement educator and student should each retain a copy of this form)

Date: Session / Week No.

Name of Student: Name of Educator:

Placement Area:

Learning outcome number

Objective Resources Achieved/Not achieved

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PgDip/MSc Occupational TherapyWEEKLY OBJECTIVES AND SUPERVISION FORM

(Practice placement educator and student should each retain a copy of this form)

Date: Session / Week No.

Name of Student: Name of Educator:

Placement Area:

Learning outcome number

Objective Resources Achieved/Not achieved

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PgDip/MSc Occupational TherapyWEEKLY OBJECTIVES AND SUPERVISION FORM

(Practice placement educator and student should each retain a copy of this form)

Date: Session / Week No.

Name of Student: Name of Educator:

Placement Area:

Learning outcome number

Objective Resources Achieved/Not achieved

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PgDip/MSc Occupational TherapyWEEKLY OBJECTIVES AND SUPERVISION FORM

(Practice placement educator and student should each retain a copy of this form)

Date: Session / Week No.

Name of Student: Name of Educator:

Placement Area:

Learning outcome number

Objective Resources Achieved/Not achieved

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Guidance for half way visits for practice placements

Purpose: To discuss student progress within learning outcomes (placement report) and ensure that objectives and opportunities are matched. (For full details see page 6 of Practice Placement Handbook 2013).

Preparation prior to the visit: Educator and student meet to discuss progress in previous supervision

session Use the university placement report to guide discussion of learning

outcomes – consider all outcomes and summarise progress in each Identify areas for development within each outcome Identify strengths within each outcome Highlight areas where there is agreement and possible disagreement

regarding the level reached within each outcome Complete university placement report – indicating half way progression

(this will be updated and completed at completion of placement)

During the visit: Allow enough time for the academic tutor to have individual private

meetings with the student and placement educator about the placement report and the progression with the learning outcomes

Establish how the student is performing, from perspective of educator and student –using the completed university placement report

By focusing on the outcomes, a pattern of strengths & weaknesses will emerge and areas for development will be evident

If there are outcomes that are less developed, consider why and establish if the student has learning opportunities available to achieve the specific learning outcome

Use the outcomes to highlight specific objectives that will allow for further development in the next part of the placement

There should be a discussion with student, educator & academic regarding agreed progression and summary of areas for development. This can be documented within the half way visit form. The student should keep a copy of this to refer to in the next part of placement. The academic will file a copy of this in the students placement file at university.

After the visit: It should be transparent after the visit what is required for the student

to continue progressing/developing. Weekly objectives will help to guide the areas requiring further

development

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Half Way Formative Assessment Form

LEARNING OUTCOMES

Each of the following learning outcomes is based on the Health and Care Professions Council’s Standards of Proficiency for Occupational Therapists (HCPC, 2013 available to download at www.hcpc-uk.org).For each learning outcome below, please mark on the scale the point which you feel reflects the student’s performance. If the student is less able to achieve the learning outcome, mark to the left hand side of the scale, and if the student is more able to achieve the learning outcome, mark to the right hand side of the scale.

In the comments box, provide feedback to assist the student in their understanding of the point at which the scale is marked. Comments should indicate strengths which the student has and areas of development which may need to be addressed in the rest of the placements.

Learning outcome 1

Unable to demonstrate the ability to practise as an autonomous professional, exercising their own professional judgement under the direction of a placement supervisor.

Able to demonstrate the ability to practise as an autonomous professional, exercising their own professional judgement under the direction of a placement supervisor.

Comments:

Strengths:

Development needs:

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Learning outcome 2

Unable to demonstrate effective self management of work load and resources.

Able to demonstrate effective self management of work load and resources.

Comments:

Strengths:

Development needs:

Learning outcome 3

Unable to demonstrate the ability to work in partnership with other staff, service users and carers.

Able to demonstrate the ability to work in partnership with other staff, service users and carers.

Comments:

Strengths:

Development needs:

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Learning outcome 4

Unable to demonstrate effective and appropriate communication skills including communication and information technologies.

Able to demonstrate effective and appropriate communication skills including communication and information technologies.

Comments:

Strengths:

Development needs:

Learning outcome 5

Unable to demonstrate knowledge of when it is appropriate to share information to safeguard service users or the wider public.

Able to demonstrate knowledge of when it is appropriate to share information to safeguard service users or the wider public.

Comments:

Strengths:

Development needs:

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Learning outcome 6

Unable to demonstrate the ability to select and use appropriate assessment techniques.

Able to demonstrate the ability to select and use appropriate assessment techniques.

Comments:

Strengths:

Development needs:

Learning outcome 7

Unable to demonstrate the use of reasoning and problem-solving skills to determine appropriate actions.

Able to demonstrate the use of reasoning and problem-solving skills to determine appropriate actions.

Comments:

Strengths:

Development needs:

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Learning outcome 8

Unable to analyse research and other evidence to inform their own practice.

Able to analyse research and other evidence to inform their own practice.

Comments:

Strengths:

Development needs:

Learning outcome 9

Unable to draw on appropriate knowledge and skills in order to make professional Judgements.

Able to draw on appropriate knowledge and skills in order to make professional Judgements.

Comments:

Strengths:

Development needs:

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Learning outcome 10

Unable to formulate specific and appropriate management plans including the setting of timescales.

Able to formulate specific and appropriate management plans including the setting of timescales.

Comments:

Strengths:

Development needs:

Learning outcome 11

Unable to demonstrate appropriate interventions or other actions safely and skilfully.

Able to demonstrate appropriate interventions or other actions safely and skilfully.

Comments:

Strengths:

Development needs:

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Learning outcome 12

Unable to demonstrate the ability to keep accurate comprehensive and comprehensible records in accordance with legislation and guidelines.

Able to demonstrate the ability to keep accurate comprehensive and comprehensible records in accordance with legislation and guidelines.

Comments:

Strengths:

Development needs:

Learning outcome 13

Unable to Monitor and review the ongoing effectiveness of planned activity and modify it accordingly.

Able to Monitor and review the ongoing effectiveness of planned activity and modify it accordingly.

Comments:

Strengths:

Development needs:

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Learning outcome 14

Unable to demonstrate the ability to reflect on and review practice.

Able to demonstrate the ability to reflect on and review practice.

Comments:

Strengths:

Development needs:

Learning outcome 15

Unable to apply the theoretical concepts underpinning occupational therapy.

Able to apply the theoretical concepts underpinning occupational therapy.

This Comments:

Strengths:

Development needs:

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Learning outcome 16

Unable to know how professional principles are expressed and translated into action through a number of different approaches to practice.

Able to know how professional principles are expressed and translated into action through a number of different approaches to practice.

Comments:

Strengths:

Development needs:

Learning outcome 17

Unable to demonstrate the need to establish and maintain a safe practice environment.

Able to demonstrate the need to establish and maintain a safe practice environment.occupational therapy.

Comments:

Strengths:

Development needs:

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Learning outcome 18

Unable to understand the importance of participation in supervision and mentoring

Able to understand the importance of participation in supervision and mentoring

Comments:

Strengths:

Development needs:

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PgDip/MSc OCCUPATIONAL THERAPY PRACTICE PLACEMENT HALF-WAY RECORD FORM

Student name……………………………………. …………………..Date: ………………………..

Placement Area: ………………………………… ………Speciality: ………………………………

Supervision taking place and recorded:

Learning Outcomes in place and evidence of progression:

Study Time:

Other/comments:

Student Signature: ………………………………………………………………….

Educator Signature: ……………………….. Name………………………………

Tutor Signature: ……………………………. Name……………………………....

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PgDip/MSc Occupational TherapyWEEKLY OBJECTIVES AND SUPERVISION FORM

(Practice placement educator and student should each retain a copy of this form)

Date: Session / Week No.

Name of Student: Name of Educator:

Placement Area:

Learning

outcome number

Objective Resources Achieved/Not achieved

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PgDip/MSc Occupational TherapyWEEKLY OBJECTIVES AND SUPERVISION FORM

(Practice placement educator and student should each retain a copy of this form)

Date: Session / Week No.

Name of Student: Name of Educator:

Placement Area:

Learning

outcome number

Objective Resources Achieved/Not achieved

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PgDip/MSc Occupational TherapyWEEKLY OBJECTIVES AND SUPERVISION FORM

(Practice placement educator and student should each retain a copy of this form)

Date: Session / Week No.

Name of Student: Name of Educator:

Placement Area:

Learning outcome number

Objective Resources Achieved/Not achieved

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PgDip/MSc Occupational TherapyWEEKLY OBJECTIVES AND SUPERVISION FORM

(Practice placement educator and student should each retain a copy of this form)

Date: Session / Week No.

Name of Student: Name of Educator:

Placement Area:

Learning outcome number

Objective Resources Achieved/Not achieved

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ASSESSING THE STUDENTS COMMUNICATION AND INTER-PERSONAL SKILLS

Aims:

To enable service users to contribute to the assessment of student communication and interpersonal skills.

To enable students to gain feedback from service users about their communication and inter-personal skills.

To provide a basis from which students can reflect upon, develop and enhance their communication and interpersonal skills.

The tool consists of an assessment sheet to be completed by patients.

The assessment tool will enable the student to build a picture of their communication skills, and inter-personal skills from a different perspective to enable them to identify areas of strengths and areas that may need developing.

Guidance for completion of the assessment tool:

In the early weeks of the placement, the placement educator will identify whether it is appropriate to service user. If is not appropriate then this will not be completed.

When appropriate the practice placement educator should ask a minimum of three service users who have had contact with the student to complete the forms. The student should not know the identity of service user providing the feedback.

Process: When the student is not present, the educator must obtain the service user informed

consent prior to them completing the feedback tool. They must provide the service user with reassurance about anonymity and confidentiality. Confirmation should be recorded on the feedback form.

The service user completes the form with the placement educator. Review should then take place between the placement educator and the student

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Feedback ToolStudent Initials:

SERVICE USER ASSESSMENT OF THE STUDENT’S COMMUNICATION AND INTERPERSONAL SKILLS

The aim of this form is to help the student Occupational Therapist develop their skills in talking to you, listening to you, and explaining things to you during your occupational therapy intervention.

This form helps you to give your opinion on what the student did well and where the student needs to improve.

The placement educator will guide you through the form. You do not have to complete this form if you choose not to.

How well did the student do at:Poor

Adequate

Good

Excellent

1. Introducing themselves?

2. Making you feel at ease?

3. Explaining what is going to happen to you?

4. Listening to you and giving you the time to talk about your concerns and opinions?

5. Making you feel that your views, decisions, and choices were respected?

6. Giving you the information you need about your care?

7. Giving you the time to ask questions and make sense of things?

8. Explaining things in a way that you could understand?

9. Checking that you understood what was said to you?

10. Treating you in a caring way?

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11. Thanking you for letting them talk to you?

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Feedback ToolStudent Initials:

SERVICE USER ASSESSMENT OF THE STUDENT’S COMMUNICATION AND INTERPERSONAL SKILLS

The aim of this form is to help the student Occupational Therapist develop their skills in talking to you, listening to you, and explaining things to you during your occupational therapy intervention.

This form helps you to give your opinion on what the student did well and where the student needs to improve.

The placement educator will guide you through the form. You do not have to complete this form if you choose not to.

How well did the student do at:Poor

Adequate

Good

Excellent

12. Introducing themselves?

13. Making you feel at ease?

14. Explaining what is going to happen to you?

15. Listening to you and giving you the time to talk about your concerns and opinions?

16. Making you feel that your views, decisions, and choices were respected?

17. Giving you the information you need about your care?

18. Giving you the time to ask questions and make sense of things?

19. Explaining things in a way that you could understand?

20. Checking that you understood what was said to you?

21. Treating you in a caring way?

22. Thanking you for letting them talk to you?

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Feedback ToolStudent Initials:

SERVICE USER ASSESSMENT OF THE STUDENT’S COMMUNICATION AND INTERPERSONAL SKILLS

The aim of this form is to help the student Occupational Therapist develop their skills in talking to you, listening to you, and explaining things to you during your occupational therapy intervention.

This form helps you to give your opinion on what the student did well and where the student needs to improve.

The placement educator will guide you through the form. You do not have to complete this form if you choose not to.

How well did the student do at:Poor

Adequate

Good

Excellent

23. Introducing themselves?

24. Making you feel at ease?

25. Explaining what is going to happen to you?

26. Listening to you and giving you the time to talk about your concerns and opinions?

27. Making you feel that your views, decisions, and choices were respected?

28. Giving you the information you need about your care?

29. Giving you the time to ask questions and make sense of things?

30. Explaining things in a way that you could understand?

31. Checking that you understood what was said to you?

32. Treating you in a caring way?

33. Thanking you for letting them talk to you?

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FINAL REPORT

LEARNING OUTCOMES

Each of the following learning outcomes are based on the Health and Care Professions Council’s Standards of Proficiency for Occupational Therapists (HCPC, 2013 available to download at www.hcpc-uk.org).

For each learning outcome below, please tick either the pass or refer box to show the progression of the student. In the comments box please provide an indication of strengths which the student has and areas of development which may need to be addressed in future placements.

Learning outcome 1

Able to demonstrate the ability to practise as an autonomous professional, exercising their own professional judgement under the direction of a placement supervisor.

Pass

Refer

Comments:

Learning outcome 2

Able to demonstrate effective self management of work load and resources. Pass

Refer

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Comments:

Learning outcome 3

Able to demonstrate the ability to work in partnership with other staff, service users and carers. Pass

Refer

Comments:

Learning outcome 4

Able to demonstrate effective and appropriate communication skills including communication and information technologies.

Pass

Refer

Comments:

Learning outcome 5

Able to demonstrate knowledge of when it is appropriate to share information to safeguard service users or the wider Pass

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public.Refer

Comments:

Learning outcome 6

Able to demonstrate the ability to gather appropriate information. Pass

Refer

Comments:

Learning outcome 7

Able to demonstrate the use of reasoning and problem-solving skills to determine appropriate actions.

Pass

ReferComments:

Learning outcome 8

Able to analyse research and other evidence to inform their own practice.

Pass

Refer

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Comments:

Learning outcome 9

Able to draw on appropriate knowledge and skills in order to make professional Judgements.

Pass

ReferComments:

Learning outcome 10

Able to formulate specific and appropriate management plans including the setting of timescales.

Pass

ReferComments:

Learning outcome 11

Able to demonstrate appropriate interventions or other actions safely and skilfully. Pass

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Refer

Comments:

Learning outcome 12

Able to demonstrate the ability to keep accurate comprehensive and comprehensible records in accordance with legislation and guidelines.

PassRefer

Comments:

Learning outcome 13

Able to Monitor and review the ongoing effectiveness of planned activity and modify it accordingly.

Pass

ReferComments:

Learning outcome 14

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Able to demonstrate the ability to reflect on and review practice. Pass

Refer

Comments:

Learning outcome 15

Able to apply the theoretical concepts underpinning occupational therapy.

Pass

Refer

Comments:

Learning outcome 16

Able to know how professional principles are expressed and translated into action through a number of different approaches to practice.

Pass

Refer

Comments:

Learning outcome 17

Pass

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Able to demonstrate the need to establish and maintain a safe practice environment. Refer

Comments:

Learning outcome 18

Able to know how professional principles are expressed and translated into action through a number of different approaches to practice.

Pass

Refer

Comments:

Learning outcome 19

Able to demonstrate the need to establish and maintain a safe practice environment.

Pass

Refer

Comments:

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Comments given by service user and carers

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OVERALL FEEDBACK

A student must be deemed to be professionally suitable in order to pass the practice placement. Educators are referred to the Code of Ethics and Professional Conduct for Occupational Therapists (2010) and the Guidance on Conduct and Ethics for Students (2009).

Please tick the appropriate box below to indicate whether the student has demonstrated consistent high standards of professional and personal conduct (HCPC 3.1).

PASS REFER

Please tick the appropriate box below to indicate whether the student has successfully met the learning outcomes.

PASS REFER

Practice Placement Educator’s Comments/Advice to the Student re. his/her overall performance………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………

Student’s Comments: ………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………

Signature of Practice Placement Educator ……………………………………Date………………..

Signature of student……………………………………………………………...Date……………….

Signature of Academic Practice Placement Organiser

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ATTENDANCE SHEETPRE-REG NURSING, MIDWIFERY, RADIOGRAPHY, PHYSIOTHERAPY, OCCUPATIONAL THERAPY & DENTAL CERT HE

Surname ……………………………………………………………………………………… Forename …………….…………………………………………..

Student Number Cohort ……………. Month ……………… Year ……….………

Date

Shifts TotalHours

Worked/ Sick

CodeClinician / Mentor

Sign toVerify

Shift worked with mentor /

supervisor? ()(for Nursing, Midwifery,

Dental Cert HE only)

CodeTimeStarted

Time Finished

1 ND – Night DutyDO – Day OffAL – Annual LeaveS – SickA – AbsentU – University / TheoryP – Placement

HoursRelate to placements only and should include the time started and finished.

Please note that you must subtract your meal break from the total hours worked column.

Hours per weekNursing 37.5Midwifery 3yr 35Midwifery 78wk 37.5Radiography 28Physiotherapy 36Occ Therapy 37.5MSc Rehab 37.5Dental

23456789

10111213141516171819202122232425262728293031

Student Signature ……………………………………………………………………………………. Date …………………………………………………….

Practice Mentor / Educator / Supervisor’s Signature

……………………………………..................................................…………………............... Date …………………………………………………….

The form should be signed by the student and countersigned by the Practice Mentor / Educator / Site Co-ordinator each month. In addition they will be checked by the Academic Mentor at the end of the tripartite meeting (nursing / midwifery) / at the end of the placement (OT) / at the final bipartite meeting (DR).

41

Page 43: sohsc.tees.ac.uk · Web viewContents Practice Placement Form2 Learning outcomes 3-4 Objective sheets for first week5-8 Half Way Visit Guidance9 Half way formative assessment form10-19

ATTENDANCE SHEETPRE-REG NURSING, MIDWIFERY, RADIOGRAPHY, PHYSIOTHERAPY, OCCUPATIONAL THERAPY & DENTAL CERT HE

Surname ……………………………………………………………………………………… Forename …………….…………………………………………..

Student Number Cohort ……………. Month ……………… Year ……….………

Date

Shifts TotalHours

Worked/ Sick

CodeClinician / Mentor

Sign toVerify

Shift worked with mentor /

supervisor? ()(for Nursing, Midwifery,

Dental Cert HE only)

CodeTimeStarted

Time Finished

1 ND – Night DutyDO – Day OffAL – Annual LeaveS – SickA – AbsentU – University / TheoryP – Placement

HoursRelate to placements only and should include the time started and finished.

Please note that you must subtract your meal break from the total hours worked column.

Hours per weekNursing 37.5Midwifery 3yr 35Midwifery 78wk 37.5Radiography 28Physiotherapy 36Occ Therapy 37.5MSc Rehab 37.5Dental

23456789

10111213141516171819202122232425262728293031

Student Signature ……………………………………………………………………………………. Date …………………………………………………….

Practice Mentor / Educator / Supervisor’s Signature

……………………………………..................................................…………………............... Date …………………………………………………….

The form should be signed by the student and countersigned by the Practice Mentor / Educator / Site Co-ordinator each month. In addition they will be checked by the Academic Mentor at the end of the tripartite meeting (nursing / midwifery) / at the end of the placement (OT) / at the final bipartite meeting (DR).

42

Page 44: sohsc.tees.ac.uk · Web viewContents Practice Placement Form2 Learning outcomes 3-4 Objective sheets for first week5-8 Half Way Visit Guidance9 Half way formative assessment form10-19

ATTENDANCE SHEETPRE-REG NURSING, MIDWIFERY, RADIOGRAPHY, PHYSIOTHERAPY, OCCUPATIONAL THERAPY & DENTAL CERT HE

Surname ……………………………………………………………………………………… Forename …………….…………………………………………..

Student Number Cohort ……………. Month ……………… Year ……….………

Date

Shifts TotalHours

Worked/ Sick

CodeClinician / Mentor

Sign toVerify

Shift worked with mentor /

supervisor? ()(for Nursing, Midwifery,

Dental Cert HE only)

CodeTimeStarted

Time Finished

1 ND – Night DutyDO – Day OffAL – Annual LeaveS – SickA – AbsentU – University / TheoryP – Placement

HoursRelate to placements only and should include the time started and finished.

Please note that you must subtract your meal break from the total hours worked column.

Hours per weekNursing 37.5Midwifery 3yr 35Midwifery 78wk 37.5Radiography 28Physiotherapy 36Occ Therapy 37.5MSc Rehab 37.5Dental

23456789

10111213141516171819202122232425262728293031

Student Signature ……………………………………………………………………………………. Date …………………………………………………….

Practice Mentor / Educator / Supervisor’s Signature

……………………………………..................................................…………………............... Date …………………………………………………….

The form should be signed by the student and countersigned by the Practice Mentor / Educator / Site Co-ordinator each month. In addition they will be checked by the Academic Mentor at the end of the tripartite meeting (nursing / midwifery) / at the end of the placement (OT) / at the final bipartite meeting (DR).

43