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{\shptxt\pard\plain\s1\nooverflow\nocwrap\lnbrkrule\li331\ri332\qc\sl240\slmult1\sb70\f2\fs24\b1 Site Declaration Form\par\pard\plain\s1\nooverflow\nocwrap\lnbrkrule\li331\ri338\qc\sl240\slmult1\f2\fs24\b1 Requirements for the \'93Nurse/Midwife Authority to Refer for Radiological Procedures\'94\par\pard\plain\s1\nooverflow\nocwrap\lnbrkrule\li3485\ri3485\qc\sl242\slmult1\sb2\f2\fs24\b1 Education Programmes (February 2022)\par}}}
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{\shptxt\pard\plain\s1\nooverflow\nocwrap\lnbrkrule\li103\ri476\sl240\slmult1\sb1\f5\fs20\b0 The above information will be populated onto the ONMSD \'93HSE National Database of Nurse and Midwife Referrers for Radiological Procedures\'94. Nurses and midwives employed in the HSE and HSE funded agencies (Section 38) are funded by the ONMSD HSE to undertake the education programme.\par\pard\plain\s1\nooverflow\nocwrap\lnbrkrule\li103\ri102\qj\sl240\slmult1\f5\fs20\b0 The\expnd-1\expndtw-5  \f5\fs20\b0\i0\expnd0\expndtw0 main\expnd0\expndtw-2  \f5\fs20\b0\i0\expnd0\expndtw0 purpose\expnd-1\expndtw-4  \f5\fs20\b0\i0\expnd0\expndtw0 of\expnd-1\expndtw-5  \f5\fs20\b0\i0\expnd0\expndtw0 the\expnd-1\expndtw-4  \f5\fs20\b0\i0\expnd0\expndtw0 database\expnd-1\expndtw-5  \f5\fs20\b0\i0\expnd0\expndtw0 is\expnd-1\expndtw-6  \f5\fs20\b0\i0\expnd0\expndtw0 to\expnd-1\expndtw-3  \f5\fs20\b0\i0\expnd0\expndtw0 provide\expnd-1\expndtw-4  \f5\fs20\b0\i0\expnd0\expndtw0 one\expnd-1\expndtw-4  \f5\fs20\b0\i0\expnd0\expndtw0 national\expnd-1\expndtw-4  \f5\fs20\b0\i0\expnd0\expndtw0 searchable\expnd-1\expndtw-4  \f5\fs20\b0\i0\expnd0\expndtw0 database,\expnd-1\expndtw-3  \f5\fs20\b0\i0\expnd0\expndtw0 which\expnd-1\expndtw-4  \f5\fs20\b0\i0\expnd0\expndtw0 is\expnd-1\expndtw-4  \f5\fs20\b0\i0\expnd0\expndtw0 only\expnd-1\expndtw-3  \f5\fs20\b0\i0\expnd0\expndtw0 accessible\expnd-1\expndtw-5  \f5\fs20\b0\i0\expnd0\expndtw0 by\expnd-1\expndtw-3  \f5\fs20\b0\i0\expnd0\expndtw0 the HSE ONMSD National Lead for Nurse Midwife Authority to Refer for Radiological Procedures. Retrieved data will be used\expnd0\expndtw-2  \f5\fs20\b0\i0\expnd0\expndtw0 to;\par\pard\plain\s1\ls1\ilvl0\nooverflow\nocwrap\lnbrkrule\li823\fi-360\ri161\sl240\slmult1\sb1\tx823\tx824\f5\fs20\b0\i0 Monitor\expnd-1\expndtw-3  \f5\fs20\b0\i0\expnd0\expndtw0 the\expnd-1\expndtw-3  \f5\fs20\b0\i0\expnd0\expndtw0 progress\expnd-1\expndtw-4  \f5\fs20\b0\i0\expnd0\expndtw0 of\expnd-1\expndtw-4  \f5\fs20\b0\i0\expnd0\expndtw0 each nurse/midwife\expnd0\expndtw-1  \f5\fs20\b0\i0\expnd0\expndtw0 funded\expnd0\expndtw-2  \f5\fs20\b0\i0\expnd0\expndtw0 by\expnd0\expndtw-2  \f5\fs20\b0\i0\expnd0\expndtw0 the\expnd-1\expndtw-4  \f5\fs20\b0\i0\expnd0\expndtw0 HSE\expnd0\expndtw-2  \f5\fs20\b0\i0\expnd0\expndtw0 from\expnd-1\expndtw-3  \f5\fs20\b0\i0\expnd0\expndtw0 commencement\expnd0\expndtw-2  \f5\fs20\b0\i0\expnd0\expndtw0 of\expnd-1\expndtw-4  \f5\fs20\b0\i0\expnd0\expndtw0 the\expnd-1\expndtw-4  \f5\fs20\b0\i0\expnd0\expndtw0 education programme and following registration on the HSE National Database of Nurse and Midwife Referrers for Radiological\expnd0\expndtw-1  \f5\fs20\b0\i0\expnd0\expndtw0 Procedures.\par\pard\plain\s1\ls1\ilvl0\nooverflow\nocwrap\lnbrkrule\li823\fi-360\ri393\sl240\slmult1\sb1\tx823\tx824\f5\fs20\b0\i0 Allow ease of data retrieval to generate standard and drillable reports at local, regional and\expnd-6\expndtw-30  \f5\fs20\b0\i0\expnd0\expndtw0 national level.\par\pard\plain\s1\ls1\ilvl0\nooverflow\nocwrap\lnbrkrule\li823\fi-360\ri627\sl240\slmult1\tx823\tx824\f5\fs20\b0\i0 Generate reports on \'93Nurse Midwife Authority to Refer for Radiological Procedures\'94 by using the information from this\expnd-1\expndtw-3  \f5\fs20\b0\i0\expnd0\expndtw0 database.\par\pard\plain\s1\nooverflow\nocwrap\lnbrkrule\li103\sl-243\f2\fs20\b1 Personal details are not disclosed for these reports. The data is used for statistical purposes only.\par}}}
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{\pard\plain\intbl\s4\nooverflow\nocwrap\lnbrkrule\li107\ri346\sl240\slmult1\sb1\f5\fs20\b0 Do you have in place local governance arrangements to oversee the introduction and implementation of Nurse Midwife Authority to Refer for Radiological Procedures?\cell}
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{\pard\plain\intbl\s4\nooverflow\nocwrap\lnbrkrule\li107\sl-243\f5\fs20\b0 Do you have in place a firm commitment by the health service provider\'92s\par\pard\plain\intbl\s4\nooverflow\nocwrap\lnbrkrule\li107\ri676\sl240\f5\fs20\b0 senior management to support the introduction of Nurse Midwife Authority to Refer for Radiological Procedures?\cell}
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{\pard\plain\intbl\s4\nooverflow\nocwrap\lnbrkrule\li107\sl240\slmult1\sb1\f5\fs20\b0 Do you have in place a named person (delegated by the Director of Nursing/Midwifery/ Service Manager/Designate) who is responsible for this initiative locally and for liaising with the applicant/student, medical practitioner, HEI and HSE National Lead for Nurse Midwife Authority to\par\pard\plain\intbl\s4\nooverflow\nocwrap\lnbrkrule\li107\sl-223\sb1\f5\fs20\b0 Refer for Radiological Procedures?\cell}
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{\pard\plain\intbl\s4\nooverflow\nocwrap\lnbrkrule\li107\ri173\sl240\slmult1\sb1\f5\fs20\b0 Do you have clinical indemnity arrangements in place for Nurse Midwife Authority to Refer for Radiological Procedures?\par\pard\plain\intbl\s4\nooverflow\nocwrap\lnbrkrule\li107\sl240\slmult1\f5\fs20\b0 (Please note the Clinical Indemnity Scheme managed by the State Claims Agency indemnifies employees of the HSE and HSE Funded Agencies\par\pard\plain\intbl\s4\nooverflow\nocwrap\lnbrkrule\li107\sl-222\f5\fs20\b0 (Section 38).\cell}
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{\pard\plain\intbl\s4\nooverflow\nocwrap\lnbrkrule\li107\ri337\sl240\slmult1\sb1\f5\fs20\b0 For HSE and HSE funded agencies (Section 38), will you have in place a signed sponsorship agreement at local service level, setting out the arrangements for study leave and financial support for the candidate? (as outlined in this form - the Declaration/Undertaking in Respect of\par\pard\plain\intbl\s4\nooverflow\nocwrap\lnbrkrule\li107\sl-223\f5\fs20\b0 Third Level Academic Fees).\cell}
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{\pard\plain\intbl\s4\nooverflow\nocwrap\lnbrkrule\li107\ri219\sl240\slmult1\sb1\f5\fs20\b0 Following successful completion of the education programme, do you agree to support the applicant\'92s timely registration \f2\fs20\b1\i0 (within 4 weeks) \f5\fs20\b0\i0 on the \'93HSE National Database of Nurse and Midwife Referrers for\par\pard\plain\intbl\s4\nooverflow\nocwrap\lnbrkrule\li107\sl-223\f5\fs20\b0 Radiological Procedures\'94?\cell}
{\pard\plain\intbl\s4\nooverflow\nocwrap\lnbrkrule\sl240\slmult1\f0\fs18\cell}
{\pard\plain\intbl\s4\nooverflow\nocwrap\lnbrkrule\sl240\slmult1\f0\fs18\cell}
{\pard\plain\intbl\s4\nooverflow\nocwrap\lnbrkrule\sl240\slmult1\f0\fs18\cell}\row
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\clvertalt\clbrdrt\brdrs\brdrcf1\brdrw10\clbrdrl\brdrs\brdrcf1\brdrw10\clbrdrr\brdrs\brdrcf1\brdrw10\clbrdrb\brdrs\brdrcf1\brdrw10\cltxlrtb\cellx6928
\clvertalt\clbrdrt\brdrs\brdrcf1\brdrw10\clbrdrl\brdrs\brdrcf1\brdrw10\clbrdrr\brdrs\brdrcf1\brdrw10\clbrdrb\brdrs\brdrcf1\brdrw10\cltxlrtb\cellx7444
\clvertalt\clbrdrt\brdrs\brdrcf1\brdrw10\clbrdrl\brdrs\brdrcf1\brdrw10\clbrdrr\brdrs\brdrcf1\brdrw10\clbrdrb\brdrs\brdrcf1\brdrw10\cltxlrtb\cellx9497
{\pard\plain\intbl\s4\nooverflow\nocwrap\lnbrkrule\li107\sl240\sb1\f5\fs20\b0 Have you identified a medical practitioner/mentor who has agreed to support the candidate throughout the education programme?\cell}
{\pard\plain\intbl\s4\nooverflow\nocwrap\lnbrkrule\sl240\slmult1\f0\fs18\cell}
{\pard\plain\intbl\s4\nooverflow\nocwrap\lnbrkrule\sl240\slmult1\f0\fs18\cell}
{\pard\plain\intbl\s4\nooverflow\nocwrap\lnbrkrule\sl240\slmult1\f0\fs18\cell}\row
\trowd\irow9\trgaph0\trrh976\trql\trleft145
\clvertalt\clbrdrt\brdrs\brdrcf1\brdrw10\clbrdrl\brdrs\brdrcf1\brdrw10\clbrdrr\brdrs\brdrcf1\brdrw10\clbrdrb\brdrs\brdrcf1\brdrw10\cltxlrtb\cellx6316
\clvertalt\clbrdrt\brdrs\brdrcf1\brdrw10\clbrdrl\brdrs\brdrcf1\brdrw10\clbrdrr\brdrs\brdrcf1\brdrw10\clbrdrb\brdrs\brdrcf1\brdrw10\cltxlrtb\cellx6928
\clvertalt\clbrdrt\brdrs\brdrcf1\brdrw10\clbrdrl\brdrs\brdrcf1\brdrw10\clbrdrr\brdrs\brdrcf1\brdrw10\clbrdrb\brdrs\brdrcf1\brdrw10\cltxlrtb\cellx7444
\clvertalt\clbrdrt\brdrs\brdrcf1\brdrw10\clbrdrl\brdrs\brdrcf1\brdrw10\clbrdrr\brdrs\brdrcf1\brdrw10\clbrdrb\brdrs\brdrcf1\brdrw10\cltxlrtb\cellx9497
{\pard\plain\intbl\s4\nooverflow\nocwrap\lnbrkrule\li107\sl240\slmult1\sb1\f5\fs20\b0 Do all stakeholders at unit level have access to the NMBI (2020) \f7\fs20\b0\i1 Nurse \f7\fs20\b0\i1 Midwife Authority to Refer for Radiological Procedures: Education Standards and Procedures \f5\fs20\b0\i0 (which includes programme learning\par\pard\plain\intbl\s4\nooverflow\nocwrap\lnbrkrule\li107\sl-223\f5\fs20\b0 outcomes, standards and required competencies)?\cell}
{\pard\plain\intbl\s4\nooverflow\nocwrap\lnbrkrule\sl240\slmult1\f0\fs18\cell}
{\pard\plain\intbl\s4\nooverflow\nocwrap\lnbrkrule\sl240\slmult1\f0\fs18\cell}
{\pard\plain\intbl\s4\nooverflow\nocwrap\lnbrkrule\sl240\slmult1\f0\fs18\cell}\row
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\clvertalt\clbrdrt\brdrs\brdrcf1\brdrw10\clbrdrl\brdrs\brdrcf1\brdrw10\clbrdrr\brdrs\brdrcf1\brdrw10\clbrdrb\brdrs\brdrcf1\brdrw10\cltxlrtb\cellx6928
\clvertalt\clbrdrt\brdrs\brdrcf1\brdrw10\clbrdrl\brdrs\brdrcf1\brdrw10\clbrdrr\brdrs\brdrcf1\brdrw10\clbrdrb\brdrs\brdrcf1\brdrw10\cltxlrtb\cellx7444
\clvertalt\clbrdrt\brdrs\brdrcf1\brdrw10\clbrdrl\brdrs\brdrcf1\brdrw10\clbrdrr\brdrs\brdrcf1\brdrw10\clbrdrb\brdrs\brdrcf1\brdrw10\cltxlrtb\cellx9497
{\pard\plain\intbl\s4\nooverflow\nocwrap\lnbrkrule\li107\sl240\slmult1\sb1\f5\fs20\b0 Can you confirm that the name of the nurse/midwife applying for the education programme is on the active register maintained by the NMBI\par\pard\plain\intbl\s4\nooverflow\nocwrap\lnbrkrule\li107\sl-222\f5\fs20\b0 i.e. has current active registration?\cell}
{\pard\plain\intbl\s4\nooverflow\nocwrap\lnbrkrule\sl240\slmult1\f0\fs18\cell}
{\pard\plain\intbl\s4\nooverflow\nocwrap\lnbrkrule\sl240\slmult1\f0\fs18\cell}
{\pard\plain\intbl\s4\nooverflow\nocwrap\lnbrkrule\sl240\slmult1\f0\fs18\cell}\row
\trowd\irow11\trgaph0\trrh244\trql\trleft145
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\clvertalt\clbrdrt\brdrs\brdrcf1\brdrw10\clbrdrl\brdrs\brdrcf1\brdrw10\clbrdrr\brdrs\brdrcf1\brdrw10\clbrdrb\brdrs\brdrcf1\brdrw10\clcbpat4\cltxlrtb\cellx6928
\clvertalt\clbrdrt\brdrs\brdrcf1\brdrw10\clbrdrl\brdrs\brdrcf1\brdrw10\clbrdrr\brdrs\brdrcf1\brdrw10\clbrdrb\brdrs\brdrcf1\brdrw10\clcbpat4\cltxlrtb\cellx7444
\clvertalt\clbrdrt\brdrs\brdrcf1\brdrw10\clbrdrl\brdrs\brdrcf1\brdrw10\clbrdrr\brdrs\brdrcf1\brdrw10\clbrdrb\brdrs\brdrcf1\brdrw10\clcbpat4\cltxlrtb\cellx9497
{\pard\plain\intbl\s4\nooverflow\nocwrap\lnbrkrule\li107\sl-223\sb1\f2\fs20\b1 Risk Management\cell}
{\pard\plain\intbl\s4\nooverflow\nocwrap\lnbrkrule\sl240\slmult1\f0\fs16\cell}
{\pard\plain\intbl\s4\nooverflow\nocwrap\lnbrkrule\sl240\slmult1\f0\fs16\cell}
{\pard\plain\intbl\s4\nooverflow\nocwrap\lnbrkrule\sl240\slmult1\f0\fs16\cell}\row
\trowd\irow12\trgaph0\trrh976\trql\trleft145
\clvertalt\clbrdrt\brdrs\brdrcf1\brdrw10\clbrdrl\brdrs\brdrcf1\brdrw10\clbrdrr\brdrs\brdrcf1\brdrw10\clbrdrb\brdrs\brdrcf1\brdrw10\cltxlrtb\cellx6316
\clvertalt\clbrdrt\brdrs\brdrcf1\brdrw10\clbrdrl\brdrs\brdrcf1\brdrw10\clbrdrr\brdrs\brdrcf1\brdrw10\clbrdrb\brdrs\brdrcf1\brdrw10\cltxlrtb\cellx6928
\clvertalt\clbrdrt\brdrs\brdrcf1\brdrw10\clbrdrl\brdrs\brdrcf1\brdrw10\clbrdrr\brdrs\brdrcf1\brdrw10\clbrdrb\brdrs\brdrcf1\brdrw10\cltxlrtb\cellx7444
\clvertalt\clbrdrt\brdrs\brdrcf1\brdrw10\clbrdrl\brdrs\brdrcf1\brdrw10\clbrdrr\brdrs\brdrcf1\brdrw10\clbrdrb\brdrs\brdrcf1\brdrw10\cltxlrtb\cellx9497
{\pard\plain\intbl\s4\nooverflow\nocwrap\lnbrkrule\li107\ri736\sl240\slmult1\sb1\f5\fs20\b0 Do you have in place local health service provider \f7\fs20\b0\i1 \'91Nurse Midwife \f7\fs20\b0\i1 Authority to Refer for Radiological Procedures\'92 \f5\fs20\b0\i0 policy, procedure,\par\pard\plain\intbl\s4\nooverflow\nocwrap\lnbrkrule\li107\sl-243\sb2\f5\fs20\b0 protocol or guideline (PPPG)? Health service providers can adopt \f7\fs20\b0\i1 the\par\pard\plain\intbl\s4\nooverflow\nocwrap\lnbrkrule\li107\sl-222\f7\fs20\b0\i1 HSE National Nurse Midwife Authority to Refer for Radiological\cell}
{\pard\plain\intbl\s4\nooverflow\nocwrap\lnbrkrule\sl240\slmult1\f0\fs18\cell}
{\pard\plain\intbl\s4\nooverflow\nocwrap\lnbrkrule\sl240\slmult1\f0\fs18\cell}
{\pard\plain\intbl\s4\nooverflow\nocwrap\lnbrkrule\sl240\slmult1\f0\fs18\cell}\row\pard\sect\sectd\sbkpage
\trowd\irow0\trgaph0\trrh489\trql\trleft145
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\clvertalt\clbrdrt\brdrs\brdrcf1\brdrw10\clbrdrl\brdrs\brdrcf1\brdrw10\clbrdrr\brdrs\brdrcf1\brdrw10\clbrdrb\brdrs\brdrcf1\brdrw10\cltxlrtb\cellx6928
\clvertalt\clbrdrt\brdrs\brdrcf1\brdrw10\clbrdrl\brdrs\brdrcf1\brdrw10\clbrdrr\brdrs\brdrcf1\brdrw10\clbrdrb\brdrs\brdrcf1\brdrw10\cltxlrtb\cellx7444
\clvertalt\clbrdrt\brdrs\brdrcf1\brdrw10\clbrdrl\brdrs\brdrcf1\brdrw10\clbrdrr\brdrs\brdrcf1\brdrw10\clbrdrb\brdrs\brdrcf1\brdrw10\cltxlrtb\cellx9497
{\pard\plain\intbl\s4\nooverflow\nocwrap\lnbrkrule\li107\ri686\sl240\sb1\f7\fs20\b0\i1 Procedures \f5\fs20\b0\i0 Guideline (2020) and develop addenda regarding local governance arrangements if they so wish.\cell}
{\pard\plain\intbl\s4\nooverflow\nocwrap\lnbrkrule\sl240\slmult1\f0\fs18\cell}
{\pard\plain\intbl\s4\nooverflow\nocwrap\lnbrkrule\sl240\slmult1\f0\fs18\cell}
{\pard\plain\intbl\s4\nooverflow\nocwrap\lnbrkrule\sl240\slmult1\f0\fs18\cell}\row
\trowd\irow1\trgaph0\trrh244\trql\trleft145
\clvertalt\clbrdrt\brdrs\brdrcf1\brdrw10\clbrdrl\brdrs\brdrcf1\brdrw10\clbrdrr\brdrs\brdrcf1\brdrw10\clbrdrb\brdrs\brdrcf1\brdrw10\cltxlrtb\cellx6316
\clvertalt\clbrdrt\brdrs\brdrcf1\brdrw10\clbrdrl\brdrs\brdrcf1\brdrw10\clbrdrr\brdrs\brdrcf1\brdrw10\clbrdrb\brdrs\brdrcf1\brdrw10\cltxlrtb\cellx6928
\clvertalt\clbrdrt\brdrs\brdrcf1\brdrw10\clbrdrl\brdrs\brdrcf1\brdrw10\clbrdrr\brdrs\brdrcf1\brdrw10\clbrdrb\brdrs\brdrcf1\brdrw10\cltxlrtb\cellx7444
\clvertalt\clbrdrt\brdrs\brdrcf1\brdrw10\clbrdrl\brdrs\brdrcf1\brdrw10\clbrdrr\brdrs\brdrcf1\brdrw10\clbrdrb\brdrs\brdrcf1\brdrw10\cltxlrtb\cellx9497
{\pard\plain\intbl\s4\nooverflow\nocwrap\lnbrkrule\li107\sl-223\sb1\f5\fs20\b0 Do you have risk management systems in place?\cell}
{\pard\plain\intbl\s4\nooverflow\nocwrap\lnbrkrule\sl240\slmult1\f0\fs16\cell}
{\pard\plain\intbl\s4\nooverflow\nocwrap\lnbrkrule\sl240\slmult1\f0\fs16\cell}
{\pard\plain\intbl\s4\nooverflow\nocwrap\lnbrkrule\sl240\slmult1\f0\fs16\cell}\row
\trowd\irow2\trgaph0\trrh244\trql\trleft145
\clvertalt\clbrdrt\brdrs\brdrcf1\brdrw10\clbrdrl\brdrs\brdrcf1\brdrw10\clbrdrr\brdrs\brdrcf1\brdrw10\clbrdrb\brdrs\brdrcf1\brdrw10\cltxlrtb\cellx6316
\clvertalt\clbrdrt\brdrs\brdrcf1\brdrw10\clbrdrl\brdrs\brdrcf1\brdrw10\clbrdrr\brdrs\brdrcf1\brdrw10\clbrdrb\brdrs\brdrcf1\brdrw10\cltxlrtb\cellx6928
\clvertalt\clbrdrt\brdrs\brdrcf1\brdrw10\clbrdrl\brdrs\brdrcf1\brdrw10\clbrdrr\brdrs\brdrcf1\brdrw10\clbrdrb\brdrs\brdrcf1\brdrw10\cltxlrtb\cellx7444
\clvertalt\clbrdrt\brdrs\brdrcf1\brdrw10\clbrdrl\brdrs\brdrcf1\brdrw10\clbrdrr\brdrs\brdrcf1\brdrw10\clbrdrb\brdrs\brdrcf1\brdrw10\cltxlrtb\cellx9497
{\pard\plain\intbl\s4\nooverflow\nocwrap\lnbrkrule\li107\sl-223\sb1\f5\fs20\b0 If yes, is there a process for;\cell}
{\pard\plain\intbl\s4\nooverflow\nocwrap\lnbrkrule\sl240\slmult1\f0\fs16\cell}
{\pard\plain\intbl\s4\nooverflow\nocwrap\lnbrkrule\sl240\slmult1\f0\fs16\cell}
{\pard\plain\intbl\s4\nooverflow\nocwrap\lnbrkrule\sl240\slmult1\f0\fs16\cell}\row
\trowd\irow3\trgaph0\trrh254\trql\trleft145
\clvertalt\clbrdrt\brdrs\brdrcf1\brdrw10\clbrdrl\brdrs\brdrcf1\brdrw10\clbrdrr\brdrs\brdrcf1\brdrw10\clbrdrb\brdrs\brdrcf1\brdrw10\cltxlrtb\cellx6316
\clvertalt\clbrdrt\brdrs\brdrcf1\brdrw10\clbrdrl\brdrs\brdrcf1\brdrw10\clbrdrr\brdrs\brdrcf1\brdrw10\clbrdrb\brdrs\brdrcf1\brdrw10\cltxlrtb\cellx6928
\clvertalt\clbrdrt\brdrs\brdrcf1\brdrw10\clbrdrl\brdrs\brdrcf1\brdrw10\clbrdrr\brdrs\brdrcf1\brdrw10\clbrdrb\brdrs\brdrcf1\brdrw10\cltxlrtb\cellx7444
\clvertalt\clbrdrt\brdrs\brdrcf1\brdrw10\clbrdrl\brdrs\brdrcf1\brdrw10\clbrdrr\brdrs\brdrcf1\brdrw10\clbrdrb\brdrs\brdrcf1\brdrw10\cltxlrtb\cellx9497
{\pard\plain\intbl\s4\ls2\ilvl0\nooverflow\nocwrap\lnbrkrule\li827\fi-361\sl-234\tx827\tx828\f5\fs20\b0\i0 Reporting and monitoring of adverse\expnd-2\expndtw-8  \f5\fs20\b0\i0\expnd0\expndtw0 event/incident\cell}
{\pard\plain\intbl\s4\nooverflow\nocwrap\lnbrkrule\sl240\slmult1\f0\fs18\cell}
{\pard\plain\intbl\s4\nooverflow\nocwrap\lnbrkrule\sl240\slmult1\f0\fs18\cell}
{\pard\plain\intbl\s4\nooverflow\nocwrap\lnbrkrule\sl240\slmult1\f0\fs18\cell}\row
\trowd\irow4\trgaph0\trrh254\trql\trleft145
\clvertalt\clbrdrt\brdrs\brdrcf1\brdrw10\clbrdrl\brdrs\brdrcf1\brdrw10\clbrdrr\brdrs\brdrcf1\brdrw10\clbrdrb\brdrs\brdrcf1\brdrw10\cltxlrtb\cellx6316
\clvertalt\clbrdrt\brdrs\brdrcf1\brdrw10\clbrdrl\brdrs\brdrcf1\brdrw10\clbrdrr\brdrs\brdrcf1\brdrw10\clbrdrb\brdrs\brdrcf1\brdrw10\cltxlrtb\cellx6928
\clvertalt\clbrdrt\brdrs\brdrcf1\brdrw10\clbrdrl\brdrs\brdrcf1\brdrw10\clbrdrr\brdrs\brdrcf1\brdrw10\clbrdrb\brdrs\brdrcf1\brdrw10\cltxlrtb\cellx7444
\clvertalt\clbrdrt\brdrs\brdrcf1\brdrw10\clbrdrl\brdrs\brdrcf1\brdrw10\clbrdrr\brdrs\brdrcf1\brdrw10\clbrdrb\brdrs\brdrcf1\brdrw10\cltxlrtb\cellx9497
{\pard\plain\intbl\s4\ls3\ilvl0\nooverflow\nocwrap\lnbrkrule\li827\fi-361\sl-234\tx827\tx828\f5\fs20\b0\i0 Reporting and monitoring of near\expnd-1\expndtw-6  \f5\fs20\b0\i0\expnd0\expndtw0 misses\cell}
{\pard\plain\intbl\s4\nooverflow\nocwrap\lnbrkrule\sl240\slmult1\f0\fs18\cell}
{\pard\plain\intbl\s4\nooverflow\nocwrap\lnbrkrule\sl240\slmult1\f0\fs18\cell}
{\pard\plain\intbl\s4\nooverflow\nocwrap\lnbrkrule\sl240\slmult1\f0\fs18\cell}\row
\trowd\irow5\trgaph0\trrh256\trql\trleft145
\clvertalt\clbrdrt\brdrs\brdrcf1\brdrw10\clbrdrl\brdrs\brdrcf1\brdrw10\clbrdrr\brdrs\brdrcf1\brdrw10\clbrdrb\brdrs\brdrcf1\brdrw10\cltxlrtb\cellx6316
\clvertalt\clbrdrt\brdrs\brdrcf1\brdrw10\clbrdrl\brdrs\brdrcf1\brdrw10\clbrdrr\brdrs\brdrcf1\brdrw10\clbrdrb\brdrs\brdrcf1\brdrw10\cltxlrtb\cellx6928
\clvertalt\clbrdrt\brdrs\brdrcf1\brdrw10\clbrdrl\brdrs\brdrcf1\brdrw10\clbrdrr\brdrs\brdrcf1\brdrw10\clbrdrb\brdrs\brdrcf1\brdrw10\cltxlrtb\cellx7444
\clvertalt\clbrdrt\brdrs\brdrcf1\brdrw10\clbrdrl\brdrs\brdrcf1\brdrw10\clbrdrr\brdrs\brdrcf1\brdrw10\clbrdrb\brdrs\brdrcf1\brdrw10\cltxlrtb\cellx9497
{\pard\plain\intbl\s4\ls4\ilvl0\nooverflow\nocwrap\lnbrkrule\li827\fi-361\sl-234\sb2\tx827\tx828\f5\fs20\b0\i0 Reporting and monitoring of referral\expnd-1\expndtw-6  \f5\fs20\b0\i0\expnd0\expndtw0 errors\cell}
{\pard\plain\intbl\s4\nooverflow\nocwrap\lnbrkrule\sl240\slmult1\f0\fs18\cell}
{\pard\plain\intbl\s4\nooverflow\nocwrap\lnbrkrule\sl240\slmult1\f0\fs18\cell}
{\pard\plain\intbl\s4\nooverflow\nocwrap\lnbrkrule\sl240\slmult1\f0\fs18\cell}\row
\trowd\irow6\trgaph0\trrh244\trql\trleft145
\clvertalt\clbrdrt\brdrs\brdrcf1\brdrw10\clbrdrl\brdrs\brdrcf1\brdrw10\clbrdrr\brdrs\brdrcf1\brdrw10\clbrdrb\brdrs\brdrcf1\brdrw10\clcbpat4\cltxlrtb\cellx6316
\clvertalt\clbrdrt\brdrs\brdrcf1\brdrw10\clbrdrl\brdrs\brdrcf1\brdrw10\clbrdrr\brdrs\brdrcf1\brdrw10\clbrdrb\brdrs\brdrcf1\brdrw10\clcbpat4\cltxlrtb\cellx6928
\clvertalt\clbrdrt\brdrs\brdrcf1\brdrw10\clbrdrl\brdrs\brdrcf1\brdrw10\clbrdrr\brdrs\brdrcf1\brdrw10\clbrdrb\brdrs\brdrcf1\brdrw10\clcbpat4\cltxlrtb\cellx7444
\clvertalt\clbrdrt\brdrs\brdrcf1\brdrw10\clbrdrl\brdrs\brdrcf1\brdrw10\clbrdrr\brdrs\brdrcf1\brdrw10\clbrdrb\brdrs\brdrcf1\brdrw10\clcbpat4\cltxlrtb\cellx9497
{\pard\plain\intbl\s4\nooverflow\nocwrap\lnbrkrule\li107\sl-223\sb1\f2\fs20\b1 Audit and Evaluation\cell}
{\pard\plain\intbl\s4\nooverflow\nocwrap\lnbrkrule\sl240\slmult1\f0\fs16\cell}
{\pard\plain\intbl\s4\nooverflow\nocwrap\lnbrkrule\sl240\slmult1\f0\fs16\cell}
{\pard\plain\intbl\s4\nooverflow\nocwrap\lnbrkrule\sl240\slmult1\f0\fs16\cell}\row
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{\pard\plain\intbl\s4\nooverflow\nocwrap\lnbrkrule\li107\ri356\sl240\slmult1\sb1\f5\fs20\b0 Do you have in place or are you planning to put in place an agreed schedule for routine audit of Nurse/Midwife Referrals for Radiological\par\pard\plain\intbl\s4\nooverflow\nocwrap\lnbrkrule\li107\sl-222\f5\fs20\b0 Procedures?\cell}
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{\pard\plain\intbl\s4\nooverflow\nocwrap\lnbrkrule\li107\sl240\sb1\f2\fs20\b1 Director of Nursing/Midwifery/ Service Manager/Designate Name: (Block Capitals)\cell}
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{\pard\plain\intbl\s4\nooverflow\nocwrap\lnbrkrule\li107\sl-243\f5\fs20\b0 Name of Health Service Provider:\cell}
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{\pard\plain\intbl\s4\nooverflow\nocwrap\lnbrkrule\li107\sl240\slmult1\sb1\f5\fs20\b0 Contact Telephone Number:\cell}
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{\pard\plain\intbl\s4\nooverflow\nocwrap\lnbrkrule\li107\sl240\slmult1\sb1\f5\fs20\b0 Work Email Address:\cell}
{\pard\plain\intbl\s4\nooverflow\nocwrap\lnbrkrule\sl240\slmult1\f0\fs18\cell}\row
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{\pard\plain\intbl\s4\nooverflow\nocwrap\lnbrkrule\li107\sl240\slmult1\sb1\f5\fs20\b0 Signature:\cell}
{\pard\plain\intbl\s4\nooverflow\nocwrap\lnbrkrule\sl240\slmult1\f0\fs18\cell}\row
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{\pard\plain\intbl\s4\nooverflow\nocwrap\lnbrkrule\li107\sl240\slmult1\sb1\f5\fs20\b0 NMBI PIN:\cell}
{\pard\plain\intbl\s4\nooverflow\nocwrap\lnbrkrule\sl240\slmult1\f0\fs18\cell}\row
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{\pard\plain\intbl\s4\nooverflow\nocwrap\lnbrkrule\li107\sl240\slmult1\sb1\f5\fs20\b0 Date:\cell}
{\pard\plain\intbl\s4\nooverflow\nocwrap\lnbrkrule\sl240\slmult1\f0\fs18\cell}\row
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{\pard\plain\intbl\s4\nooverflow\nocwrap\lnbrkrule\li107\sl-223\sb1\f2\fs20\b1 Medical Practitioner/Mentor Name: (Block Capitals)\cell}
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{\pard\plain\intbl\s4\nooverflow\nocwrap\lnbrkrule\li107\sl240\slmult1\sb1\f5\fs20\b0 Name of Health Service Provider:\cell}
{\pard\plain\intbl\s4\nooverflow\nocwrap\lnbrkrule\sl240\slmult1\f0\fs18\cell}\row
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{\pard\plain\intbl\s4\nooverflow\nocwrap\lnbrkrule\li107\sl240\slmult1\sb1\f5\fs20\b0 Contact Telephone Number:\cell}
{\pard\plain\intbl\s4\nooverflow\nocwrap\lnbrkrule\sl240\slmult1\f0\fs18\cell}\row
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{\pard\plain\intbl\s4\nooverflow\nocwrap\lnbrkrule\li107\sl240\slmult1\sb1\f5\fs20\b0 Work Email Address:\cell}
{\pard\plain\intbl\s4\nooverflow\nocwrap\lnbrkrule\sl240\slmult1\f0\fs18\cell}\row
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{\pard\plain\intbl\s4\nooverflow\nocwrap\lnbrkrule\li107\sl240\slmult1\sb1\f5\fs20\b0 Signature:\cell}
{\pard\plain\intbl\s4\nooverflow\nocwrap\lnbrkrule\sl240\slmult1\f0\fs18\cell}\row
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{\pard\plain\intbl\s4\nooverflow\nocwrap\lnbrkrule\li107\sl-243\f5\fs20\b0 Medical Council Registration Number (MCRN):\cell}
{\pard\plain\intbl\s4\nooverflow\nocwrap\lnbrkrule\sl240\slmult1\f0\fs18\cell}\row
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{\pard\plain\intbl\s4\nooverflow\nocwrap\lnbrkrule\li107\sl240\slmult1\sb1\f5\fs20\b0 Date:\cell}
{\pard\plain\intbl\s4\nooverflow\nocwrap\lnbrkrule\sl240\slmult1\f0\fs18\cell}\row
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{\pard\plain\intbl\s4\nooverflow\nocwrap\lnbrkrule\li107\sl-243\sb1\f2\fs20\b1 Printed Head of Radiology (Consultant Radiologist)\par\pard\plain\intbl\s4\nooverflow\nocwrap\lnbrkrule\li107\sl-222\f2\fs20\b1 Name: (Block Capitals)\cell}
{\pard\plain\intbl\s4\nooverflow\nocwrap\lnbrkrule\sl240\slmult1\f0\fs18\cell}\row
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{\pard\plain\intbl\s4\nooverflow\nocwrap\lnbrkrule\li107\sl240\slmult1\sb2\f5\fs20\b0 Name of Health Service Provider:\cell}
{\pard\plain\intbl\s4\nooverflow\nocwrap\lnbrkrule\sl240\slmult1\f0\fs18\cell}\row
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{\pard\plain\intbl\s4\nooverflow\nocwrap\lnbrkrule\li107\sl240\slmult1\sb1\f5\fs20\b0 Contact Telephone Number:\cell}
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{\pard\plain\intbl\s4\nooverflow\nocwrap\lnbrkrule\li107\sl240\slmult1\sb1\f5\fs20\b0 Work Email Address:\cell}
{\pard\plain\intbl\s4\nooverflow\nocwrap\lnbrkrule\sl240\slmult1\f0\fs18\cell}\row
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{\pard\plain\intbl\s4\nooverflow\nocwrap\lnbrkrule\li107\sl240\slmult1\sb1\f5\fs20\b0 Signature:\cell}
{\pard\plain\intbl\s4\nooverflow\nocwrap\lnbrkrule\sl240\slmult1\f0\fs18\cell}\row
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{\pard\plain\intbl\s4\nooverflow\nocwrap\lnbrkrule\li107\sl240\slmult1\sb1\f5\fs20\b0 Medical Council Registration Number (MCRN):\cell}
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{\pard\plain\intbl\s4\nooverflow\nocwrap\lnbrkrule\li107\sl-243\f5\fs20\b0 Date:\cell}
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{\pard\plain\intbl\s4\nooverflow\nocwrap\lnbrkrule\sl240\slmult1\sb1\f2\fs24\b1\i0\par\pard\plain\intbl\s4\nooverflow\nocwrap\lnbrkrule\li1398\ri1391\qc\sl240\slmult1\f2\fs24\b1 Declaration /Undertaking in Respect of Third level Academic Fees\cell}\row
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{\pard\plain\intbl\s4\nooverflow\nocwrap\lnbrkrule\li107\sl-292\f5\fs24\b0 Applicant\'92s Declaration/Undertaking in respect of Third level Academic fees for Nurse Midwife\par\pard\plain\intbl\s4\nooverflow\nocwrap\lnbrkrule\li107\sl-273\f5\fs24\b0 Authority to Refer for Radiological Procedures education programme.\cell}\row
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{\pard\plain\intbl\s4\nooverflow\nocwrap\lnbrkrule\li107\sl240\slmult1\sb1\f2\fs24\b1 On successful completion of the education programme I will be required to:\par\pard\plain\intbl\s4\ls5\ilvl0\nooverflow\nocwrap\lnbrkrule\li827\fi-360\ri102\sl240\slmult1\tx828\f5\fs24\b0 Provide my employing agency with evidence of my successful completion of the programme as per HSE HR Circular 020/2014 Section\expnd-1\expndtw-4  \f5\fs24\b0\i0\expnd0\expndtw0 9\par\pard\plain\intbl\s4\ls5\ilvl0\nooverflow\nocwrap\lnbrkrule\li827\fi-360\ri97\sl240\slmult1\tx882\tx883 \tab \f5\fs24\b0 Inform the National Lead for Nurse Midwife Authority to Refer for Radiological Procedures by email at\expnd-1\expndtw-3\cf3  {\field {\fldinst { HYPERLINK "mailto:nurse.prescribing@hse.ie" }}{\fldrslt \f2\fs24\b1\i0\expnd0\expndtw0{\ul nurse.prescribing@hse.ie}}
}\f2\fs24\b1\i0\expnd0\expndtw0 {\ul }.\par\pard\plain\intbl\s4\nooverflow\nocwrap\lnbrkrule\sl240\slmult1\sb11\f2\fs23\b1\i0\par\pard\plain\intbl\s4\nooverflow\nocwrap\lnbrkrule\li107\ri99\qj\sl240\slmult1\f5\fs24\b0 I\expnd-1\expndtw-5  \f5\fs24\b0\i0\expnd0\expndtw0 understand\expnd-1\expndtw-6  \f5\fs24\b0\i0\expnd0\expndtw0 that\expnd-1\expndtw-6  \f5\fs24\b0\i0\expnd0\expndtw0 proposed\expnd-1\expndtw-5  \f5\fs24\b0\i0\expnd0\expndtw0 leave\expnd-1\expndtw-7  \f5\fs24\b0\i0\expnd0\expndtw0 entitlements\expnd-1\expndtw-7  \f5\fs24\b0\i0\expnd0\expndtw0 will\expnd-1\expndtw-5  \f5\fs24\b0\i0\expnd0\expndtw0 be\expnd-1\expndtw-4  \f5\fs24\b0\i0\expnd0\expndtw0 subject\expnd-1\expndtw-5  \f5\fs24\b0\i0\expnd0\expndtw0 to\expnd-1\expndtw-7  \f5\fs24\b0\i0\expnd0\expndtw0 staffing\expnd-2\expndtw-8  \f5\fs24\b0\i0\expnd0\expndtw0 demands\expnd-1\expndtw-7  \f5\fs24\b0\i0\expnd0\expndtw0 at\expnd-2\expndtw-8  \f5\fs24\b0\i0\expnd0\expndtw0 the\expnd-2\expndtw-8  \f5\fs24\b0\i0\expnd0\expndtw0 time. I further agree that the entirety of the course fees paid by the HSE on my behalf will immediately become due and owing by me to the HSE if\expnd-1\expndtw-3  \f5\fs24\b0\i0\expnd0\expndtw0 I:\par\pard\plain\intbl\s4\ls6\ilvl0\nooverflow\nocwrap\lnbrkrule\li827\fi-360\ri100\qj\sl240\slmult1\sb121\tx828\f5\fs24\b0 Do not complete the programme successfully within the time frame designated by the relevant Higher Education Institution\par\pard\plain\intbl\s4\ls6\ilvl0\nooverflow\nocwrap\lnbrkrule\li827\fi-360\ri100\qj\sl240\slmult1\sb119\tx828\f5\fs24\b0 Cease employment with the Health Service Executive before I have successfully completed the\expnd0\expndtw-1  \f5\fs24\b0\i0\expnd0\expndtw0 programme\par\pard\plain\intbl\s4\ls6\ilvl0\nooverflow\nocwrap\lnbrkrule\li827\fi-360\ri457\qj\sl240\slmult1\sb120\tx828\f5\fs24\b0 Cease employment with the Health Service Executive at any time following successful\expnd-1\expndtw-5  \f5\fs24\b0\i0\expnd0\expndtw0 completion\expnd-1\expndtw-4  \f5\fs24\b0\i0\expnd0\expndtw0 of\expnd-2\expndtw-8  \f5\fs24\b0\i0\expnd0\expndtw0 the\expnd-1\expndtw-6  \f5\fs24\b0\i0\expnd0\expndtw0 programme\expnd-1\expndtw-6  \f5\fs24\b0\i0\expnd0\expndtw0 within\expnd-1\expndtw-6  \f5\fs24\b0\i0\expnd0\expndtw0 the\expnd-1\expndtw-3  \f5\fs24\b0\i0\expnd0\expndtw0 period\expnd-1\expndtw-5  \f5\fs24\b0\i0\expnd0\expndtw0 of\expnd-1\expndtw-6  \f5\fs24\b0\i0\expnd0\expndtw0 twelve\expnd-1\expndtw-6  \f5\fs24\b0\i0\expnd0\expndtw0 months\expnd-1\expndtw-4  \f5\fs24\b0\i0\expnd0\expndtw0 or\expnd-1\expndtw-6  \f5\fs24\b0\i0\expnd0\expndtw0 for the length of the academic course undertaken whichever is\expnd-2\expndtw-8  \f5\fs24\b0\i0\expnd0\expndtw0 longer\f2\b1 .\par\pard\plain\intbl\s4\nooverflow\nocwrap\lnbrkrule\sl240\slmult1\sb10\f2\fs19\b1\i0\par\pard\plain\intbl\s4\nooverflow\nocwrap\lnbrkrule\li107\ri102\qj\sl240\slmult1\f7\fs24\b0\i1 I agree to repay the amount of fees paid for me in respect of this programme and salary on a \f7\fs24\b0\i1 pro rata basis for full time programmes.\par\pard\plain\intbl\s4\nooverflow\nocwrap\lnbrkrule\li107\qj\sl240\slmult1\sb60\tx4342\tx5148\tx8474\f5\fs24\b0 Signed:{\ul\ulc1  \tab }\tab Date:{\ul\ulc1  \tab }\cell}\row
\trowd\irow3\trgaph0\trrh592\trql\trleft141
\clvertalt\clbrdrt\brdrs\brdrcf1\brdrw15\clbrdrl\brdrs\brdrcf1\brdrw10\clbrdrr\brdrs\brdrcf1\brdrw10\clbrdrb\brdrs\brdrcf1\brdrw10\clcbpat4\cltxlrtb\cellx9498
{\pard\plain\intbl\s4\nooverflow\nocwrap\lnbrkrule\sl240\slmult1\sb7\f2\fs19\b1\i0\par\pard\plain\intbl\s4\nooverflow\nocwrap\lnbrkrule\li107\sl240\slmult1\f7\fs24\b0\i1 Director of Nursing/Midwifery\f5\i0 /\f7\i1 Service Manager /Designate Approval and Sign-Off\cell}\row
\trowd\irow4\trgaph0\trrh1180\trql\trleft141
\clvertalt\clbrdrt\brdrs\brdrcf1\brdrw10\clbrdrl\brdrs\brdrcf1\brdrw10\clbrdrr\brdrs\brdrcf1\brdrw10\clbrdrb\brdrs\brdrcf1\brdrw15\cltxlrtb\cellx9498
{\pard\plain\intbl\s4\nooverflow\nocwrap\lnbrkrule\sl240\slmult1\sb11\f2\fs23\b1\i0\par\pard\plain\intbl\s4\nooverflow\nocwrap\lnbrkrule\li107\sl240\slmult1\tx4342\tx5148\tx8474\f5\fs24\b0 Signed:{\ul\ulc1  \tab }\tab Date:{\ul\ulc1  \tab }\cell}\row
\trowd\irow5\trgaph0\trrh1991\trql\trleft141
\clvertalt\clbrdrt\brdrs\brdrcf1\brdrw15\clbrdrl\brdrs\brdrcf1\brdrw10\clbrdrr\brdrs\brdrcf1\brdrw10\clbrdrb\brdrs\brdrcf1\brdrw15\cltxlrtb\cellx9498
{\pard\plain\intbl\s4\nooverflow\nocwrap\lnbrkrule\li107\sl-292\f5\fs24\b0 Director of Nursing/Midwifery\f7\i1 /\f5\i0 Service Manager/Designate Comments (\f7\i1 optional\f5\i0 ):\cell}\row\pard\sect\sectd\sbkpage\margtsxn940\pard\plain\s2\nooverflow\nocwrap\lnbrkrule\li140\sl240\slmult1\sb25\f2\fs24\b1 Check List\par\pard\plain\s1\nooverflow\nocwrap\lnbrkrule\sl240\slmult1\sb2\sa1\f2\fs24\b1\i0\par
\trowd\irow0\trgaph0\trrh585\trql\trleft145
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{\pard\plain\intbl\s4\nooverflow\nocwrap\lnbrkrule\li107\sl-293\f2\fs24\b1 Each of the following must be ticked as evidence of completion\cell}\row
\trowd\irow1\trgaph0\trrh877\trql\trleft145
\clvertalt\clbrdrt\brdrs\brdrcf1\brdrw10\clbrdrl\brdrs\brdrcf1\brdrw10\clbrdrr\brdrs\brdrcf1\brdrw10\clbrdrb\brdrs\brdrcf1\brdrw10\clcbpat4\cltxlrtb\cellx995
\clvertalt\clbrdrt\brdrs\brdrcf1\brdrw10\clbrdrl\brdrs\brdrcf1\brdrw10\clbrdrr\brdrs\brdrcf1\brdrw10\clbrdrb\brdrs\brdrcf1\brdrw10\clcbpat4\cltxlrtb\cellx8130
\clvertalt\clbrdrt\brdrs\brdrcf1\brdrw10\clbrdrl\brdrs\brdrcf1\brdrw10\clbrdrr\brdrs\brdrcf1\brdrw10\clbrdrb\brdrs\brdrcf1\brdrw10\clcbpat4\cltxlrtb\cellx9499
{\pard\plain\intbl\s4\nooverflow\nocwrap\lnbrkrule\li107\sl-292\f2\fs24\b1 1.\cell}
{\pard\plain\intbl\s4\nooverflow\nocwrap\lnbrkrule\li107\ri-3\sl240\slmult1\f5\fs24\b0 The form is \f2\fs24\b1\i0 fully \f5\fs24\b0\i0 completed. Incomplete forms will be returned to you and may not be considered\cell}
{\pard\plain\intbl\s4\nooverflow\nocwrap\lnbrkrule\sl240\slmult1\f0\fs22\cell}\row
\trowd\irow2\trgaph0\trrh880\trql\trleft145
\clvertalt\clbrdrt\brdrs\brdrcf1\brdrw10\clbrdrl\brdrs\brdrcf1\brdrw10\clbrdrr\brdrs\brdrcf1\brdrw10\clbrdrb\brdrs\brdrcf1\brdrw10\clcbpat4\cltxlrtb\cellx995
\clvertalt\clbrdrt\brdrs\brdrcf1\brdrw10\clbrdrl\brdrs\brdrcf1\brdrw10\clbrdrr\brdrs\brdrcf1\brdrw10\clbrdrb\brdrs\brdrcf1\brdrw10\clcbpat4\cltxlrtb\cellx8130
\clvertalt\clbrdrt\brdrs\brdrcf1\brdrw10\clbrdrl\brdrs\brdrcf1\brdrw10\clbrdrr\brdrs\brdrcf1\brdrw10\clbrdrb\brdrs\brdrcf1\brdrw10\clcbpat4\cltxlrtb\cellx9499
{\pard\plain\intbl\s4\nooverflow\nocwrap\lnbrkrule\li107\sl-292\f2\fs24\b1 2.\cell}
{\pard\plain\intbl\s4\nooverflow\nocwrap\lnbrkrule\li107\ri-3\sl240\slmult1\f5\fs24\b0 This fully completed form must be submitted to the relevant HEI as part of the application process by the application closing date\cell}
{\pard\plain\intbl\s4\nooverflow\nocwrap\lnbrkrule\sl240\slmult1\f0\fs22\cell}\row
\trowd\irow3\trgaph0\trrh1757\trql\trleft145
\clvertalt\clbrdrt\brdrs\brdrcf1\brdrw10\clbrdrl\brdrs\brdrcf1\brdrw10\clbrdrr\brdrs\brdrcf1\brdrw10\clbrdrb\brdrs\brdrcf1\brdrw10\clcbpat4\cltxlrtb\cellx995
\clvertalt\clbrdrt\brdrs\brdrcf1\brdrw10\clbrdrl\brdrs\brdrcf1\brdrw10\clbrdrr\brdrs\brdrcf1\brdrw10\clbrdrb\brdrs\brdrcf1\brdrw10\clcbpat4\cltxlrtb\cellx8130
\clvertalt\clbrdrt\brdrs\brdrcf1\brdrw10\clbrdrl\brdrs\brdrcf1\brdrw10\clbrdrr\brdrs\brdrcf1\brdrw10\clbrdrb\brdrs\brdrcf1\brdrw10\clcbpat4\cltxlrtb\cellx9499
{\pard\plain\intbl\s4\nooverflow\nocwrap\lnbrkrule\li107\sl-292\f2\fs24\b1 3.\cell}
{\pard\plain\intbl\s4\nooverflow\nocwrap\lnbrkrule\li107\ri285\sl240\slmult1\f5\fs24\b0 A copy of this completed form must be emailed to the National Lead for Nurse Midwife Authority to Refer for Radiological Procedures at {\field {\fldinst { HYPERLINK "mailto:nurse.prescribing@hse.ie" }}{\fldrslt \f5\fs24\b0\i0\cf3{\ul nurse.prescribing@hse.ie} }}
\f5\fs24\b0\i0\cf3 \f5\fs24\b0\i0\cf1 by nurses/midwives employed in the HSE and HSE funded agencies (Section 38) by the relevant HEI application closing date.\cell}
{\pard\plain\intbl\s4\nooverflow\nocwrap\lnbrkrule\sl240\slmult1\f0\fs22\cell}\row
\trowd\irow4\trgaph0\trrh1173\trql\trleft145
\clvertalt\clbrdrt\brdrs\brdrcf1\brdrw10\clbrdrl\brdrs\brdrcf1\brdrw10\clbrdrr\brdrs\brdrcf1\brdrw10\clbrdrb\brdrs\brdrcf1\brdrw10\clcbpat4\cltxlrtb\cellx995
\clvertalt\clbrdrt\brdrs\brdrcf1\brdrw10\clbrdrl\brdrs\brdrcf1\brdrw10\clbrdrr\brdrs\brdrcf1\brdrw10\clbrdrb\brdrs\brdrcf1\brdrw10\clcbpat4\cltxlrtb\cellx8130
\clvertalt\clbrdrt\brdrs\brdrcf1\brdrw10\clbrdrl\brdrs\brdrcf1\brdrw10\clbrdrr\brdrs\brdrcf1\brdrw10\clbrdrb\brdrs\brdrcf1\brdrw10\clcbpat4\cltxlrtb\cellx9499
{\pard\plain\intbl\s4\nooverflow\nocwrap\lnbrkrule\li107\sl-292\f2\fs24\b1 4.\cell}
{\pard\plain\intbl\s4\nooverflow\nocwrap\lnbrkrule\li107\ri103\qj\sl240\slmult1\f5\fs24\b0 The\expnd-2\expndtw-12  \f5\fs24\b0\i0\expnd0\expndtw0 name\expnd-2\expndtw-11  \f5\fs24\b0\i0\expnd0\expndtw0 of\expnd-2\expndtw-12  \f5\fs24\b0\i0\expnd0\expndtw0 the\expnd-2\expndtw-11  \f5\fs24\b0\i0\expnd0\expndtw0 applicant\expnd-2\expndtw-10  \f5\fs24\b0\i0\expnd0\expndtw0 on\expnd-2\expndtw-10  \f5\fs24\b0\i0\expnd0\expndtw0 the\expnd-2\expndtw-11  \f5\fs24\b0\i0\expnd0\expndtw0 application\expnd-2\expndtw-9  \f5\fs24\b0\i0\expnd0\expndtw0 form\expnd-3\expndtw-13  \f5\fs24\b0\i0\expnd0\expndtw0 is\expnd-2\expndtw-9  \f5\fs24\b0\i0\expnd0\expndtw0 the\expnd-2\expndtw-12  \f5\fs24\b0\i0\expnd0\expndtw0 name\expnd-2\expndtw-11  \f5\fs24\b0\i0\expnd0\expndtw0 by\expnd-2\expndtw-12  \f5\fs24\b0\i0\expnd0\expndtw0 which they are registered with the NMBI and which will appear on their student ID card, college records and\expnd-1\expndtw-3  \f5\fs24\b0\i0\expnd0\expndtw0 parchment.\cell}
{\pard\plain\intbl\s4\nooverflow\nocwrap\lnbrkrule\sl240\slmult1\f0\fs22\cell}\row
\trowd\irow5\trgaph0\trrh585\trql\trleft145
\clvertalt\clbrdrt\brdrs\brdrcf1\brdrw10\clbrdrl\brdrs\brdrcf1\brdrw10\clbrdrr\brdrs\brdrcf1\brdrw10\clbrdrb\brdrs\brdrcf1\brdrw10\clcbpat4\cltxlrtb\cellx995
\clvertalt\clbrdrt\brdrs\brdrcf1\brdrw10\clbrdrl\brdrs\brdrcf1\brdrw10\clbrdrr\brdrs\brdrcf1\brdrw10\clbrdrb\brdrs\brdrcf1\brdrw10\clcbpat4\cltxlrtb\cellx8130
\clvertalt\clbrdrt\brdrs\brdrcf1\brdrw10\clbrdrl\brdrs\brdrcf1\brdrw10\clbrdrr\brdrs\brdrcf1\brdrw10\clbrdrb\brdrs\brdrcf1\brdrw10\clcbpat4\cltxlrtb\cellx9499
{\pard\plain\intbl\s4\nooverflow\nocwrap\lnbrkrule\li107\sl-292\f2\fs24\b1 5.\cell}
{\pard\plain\intbl\s4\nooverflow\nocwrap\lnbrkrule\li107\sl-292\f5\fs24\b0 A copy of this completed form has been retained by the employer.\cell}
{\pard\plain\intbl\s4\nooverflow\nocwrap\lnbrkrule\sl240\slmult1\f0\fs22\cell}\row\pard\pard\plain\s1\nooverflow\nocwrap\lnbrkrule\sl240\slmult1\f2\fs24\b1\i0\par\pard\plain\s1\nooverflow\nocwrap\lnbrkrule\sl240\slmult1\sb11\f2\fs23\b1\i0\par\pard\plain\s1\nooverflow\nocwrap\lnbrkrule\li140\sl240\slmult1\tx8371\f2\fs24\b1 Applicants Name: (Block\expnd-2\expndtw-12  \f2\fs24\b1\i0\expnd0\expndtw0 Capitals) {\ulth  \tab }\par\pard\plain\s1\nooverflow\nocwrap\lnbrkrule\sl240\slmult1\f2\fs20\b1\i0\par\pard\plain\s1\nooverflow\nocwrap\lnbrkrule\sl240\slmult1\sb9\f2\fs23\b1\i0\par\pard\plain\s1\nooverflow\nocwrap\lnbrkrule\li140\sl240\slmult1\sb52\tx6161\f2\fs24\b1 Signature:\expnd0\expndtw1  \expnd0\expndtw0{\ulth  \tab }\par\pard\plain\s1\nooverflow\nocwrap\lnbrkrule\sl240\slmult1\f2\fs20\b1\i0\par\pard\plain\s1\nooverflow\nocwrap\lnbrkrule\sl240\slmult1\sb11\f2\fs23\b1\i0\par\pard\plain\s1\nooverflow\nocwrap\lnbrkrule\li140\sl240\slmult1\sb52\tx6178\f2\fs24\b1 NMBI\expnd-1\expndtw-3  \f2\fs24\b1\i0\expnd0\expndtw0 PIN:\expnd0\expndtw-1  \expnd0\expndtw0{\ulth  \tab }\par\pard\plain\s1\nooverflow\nocwrap\lnbrkrule\sl240\slmult1\f2\fs20\b1\i0\par\pard\plain\s1\nooverflow\nocwrap\lnbrkrule\sl240\slmult1\sb9\f2\fs23\b1\i0\par\pard\plain\s1\nooverflow\nocwrap\lnbrkrule\li140\sl240\slmult1\sb51\tx6161\f2\fs24\b1 Date:\expnd0\expndtw1  \expnd0\expndtw0{\ulth  \tab }\par\pard\plain\s1\nooverflow\nocwrap\lnbrkrule\sl240\slmult1\f2\fs20\b1\i0\par\pard\plain\s1\nooverflow\nocwrap\lnbrkrule\sl240\slmult1\f2\fs20\b1\i0\par\pard\plain\s1\nooverflow\nocwrap\lnbrkrule\sl240\slmult1\f2\fs20\b1\i0\par\pard\plain\s1\nooverflow\nocwrap\lnbrkrule\sl240\slmult1\f2\fs20\b1\i0\par\pard\plain\s1\nooverflow\nocwrap\lnbrkrule\sl240\slmult1\f2\fs20\b1\i0\par\pard\plain\s1\nooverflow\nocwrap\lnbrkrule\sl240\slmult1\f2\fs20\b1\i0\par\pard\plain\s1\nooverflow\nocwrap\lnbrkrule\sl240\slmult1\f2\fs20\b1\i0\par\pard\plain\s1\nooverflow\nocwrap\lnbrkrule\sl240\slmult1\f2\fs20\b1\i0\par\pard\plain\s1\nooverflow\nocwrap\lnbrkrule\sl240\slmult1\f2\fs20\b1\i0\par\pard\plain\s1\nooverflow\nocwrap\lnbrkrule\sl240\slmult1\f2\fs20\b1\i0\par\pard\plain\s1\nooverflow\nocwrap\lnbrkrule\sl240\slmult1\f2\fs20\b1\i0\par\pard\plain\s1\nooverflow\nocwrap\lnbrkrule\sl240\slmult1\sb4\f2\fs23\b1\i0\par\pard\plain\s1\nooverflow\nocwrap\lnbrkrule\li140\sl240\slmult1\sb59\f2\fs20\b1 (Version February 2022)\par}