3rd level Placement Form - St. Francis Hospice

Home » For Healthcare Professionals » Education » College Affiliates » 3rd level Placement Form

Clinical Placement Application Form

This field is hidden when viewing the form

Next Steps: Sync an Email Add-On

To get the most out of your form, we suggest that you sync this form with an email add-on. To learn more about your email add-on options, visit the following page (https://www.gravityforms.com/the-8-best-email-plugins-for-wordpress-in-2020/). Important: Delete this tip before you publish the form.

Your Name(Required)

First Last

Your Address

Street Address Address Line 2 City Eircode/Postal Code Country

Your Email Address(Required)

Email Address Confirm Email Address

Your Phone Number(Required)

Emergency Person Contact Phone No:(Required)

Emergency Person Contact Name(Required)

Emergency Person Contact email(Required)

Your Current Position/Discipline(Required)

If placement is in relation to a course; Name of Educational Institution(Required)

Course Name(Required)

Name of Contact Person in Educational Institute(Required)

Phone number for Contact Person in Educational Institute(Required)

Email for Contact Person(Required)

Is there a clinical assessment required during/on completion of placement?(Required)

Yes-(if yes a copy of the assessment form must be provided)

Who needs to complete the assessment?(Required)

Start Date

End Date

Number of hours for placement(Required)

Preferred Location(Required)

*We will endeavour to facilitate your preferred location, but this may not always be possible.

Days Preferred(Required)

*We will endeavour to facilitate your preferred days, but this may not always be possible.

What do you hope to achieve from this placement?

Professional Registration/Student Registration Certificate. Please Upload File Below.(Required)

Drop files here or

Max. file size: 50 MB.

Copy of Garda Vetting:(Required)

Max. file size: 50 MB.

For applicants who are students in the Republic of Ireland, please request a copy of your Garda clearance certificate from your college. All other applicants must be Garda vetted by St. Francis Hospice Dublin. Please request the required forms from St. Francis Hospice Dublin.

HSELand AMRIC Standard and Transmission Based Precautions, dated within the last 2 years. Upload Certificate(Required)

Max. file size: 50 MB.

HSELand AMRIC Hand Hygiene Training, dated within the last 2 years. Upload Certificate(Required)

Max. file size: 50 MB.

HSELand Fundamentals of GDPR Training .Upload Certificate(Required)

Max. file size: 50 MB.

HSELand An Introduction to Childrens First Training- dated within the last 2 years. Please Upload Certificate(Required)

Max. file size: 50 MB.

Safeguarding Podcast (25 minutes long) . Please watch and then answer questions below Safeguarding Podcast

1. Who is responsible for Child Safeguarding in St Francis Hospice(Required)

Can children play unsupervised in the playrooms of the Hospice?(Required)

Case Study 1-What type of abuse is this?(Required)

Do You(Required)

Case Study 2-What are the main issues?(Required)

Do You(Required)

3. What issues, if any do you feel you need further training on the issue of Safeguarding?

Safeguarding - A guideline for Students and Volunteers. Please read and sign below: Safeguarding- A guideline for Students and Volunteers

Is English your first language?(Required)

*If your first language is not English, and if you have not been educated through the medium of English, you must present a proof of English language qualification – Refer to Appendix 1 for acceptable evidence.

Appendix 1 - All applicants whose first language is not English and who have not been educated through the medium of English must present one of the following qualifications in the English language: IELTS (Academic version) and IELTS Indicator Grade 6.5 overall TOEFL and TOEFL iBT Special Home Edition: 88 internet-based, 570 paper-based, 230 computer-based University of Cambridge: Proficiency Certificate Grade C or better (CEFR Level C1 or C2) University of Cambridge: Advanced Certificate Grade C or better (CEFR Level C1 or C2 Pearson Test of English (Academic) - PTE Academic  A minimum score of 63 to be eligible (with no section score below 59) Duolingo English Test Minimum overall score of 120.

Proof of English Language Certification. Please Upload File Below

Max. file size: 50 MB.

CAPTCHA

Name

This field is for validation purposes and should be left unchanged.

PARKING: Both of our locations offer free and seasy parking

INFORMATION: Lorem ipsum dolor sit amet, consectetur adipiscing elit. Sed egestas faucibus metus, at convallis sapien gravida vitae.

recruitment@sfh.ie

Station road, Raheny Dublin D05 e392

Get Directions

01 832 7535

Blanchardstown Dublin D15 DE98

Get Directions

01 829 4000