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1 Dr. G.W.Tobin MD, FRCPI, FRCP, Cert.Med.Ed. Academy Medical Dean Miss Sheena Tranter FRCS Deputy Academy Dean Bristol South Academy Dolphin House Bristol Royal Infirmary, Bristol, BS2 8HW Dr. Kate Reading MBBS, MSc (TLHP), MRCP Telephone: (0117) /2256 Deputy Academy Dean Suzan Fowweather Academy Manager Sue Bamford Academy Undergraduate Administrator Philip Collings Academy Undergraduate Administrator Accommodation: You will be accommodated, free of charge, in a single room in a Hospital property, which is situated within walking distance the Bristol Royal Infirmary. Please collect your key from the Porters Office (at the main entrance of the Bristol Royal Infirmary, Queens Building on Marlborough Street), which is open 24 hours a day. You may occupy the room from (please advise your exact date you will be arriving). Cooking facilities are available, bed linen is provided, but you should bring your own towels, there is a public laundrette nearby. Identification: ID badges can be obtained through Medical Illustration; we will give you the appropriate form when you come to our office on your first day. These badges should be given to either your supervisor or this office on departure from the BRI. Language: You should be aware that most of the teaching in Bristol is small group teaching, which takes place in the wards and clinics of the hospitals. In order to benefit from this teaching you should ensure that your English Language skills are at least equivalent of Level 7 of the British Council English Language test. Immunisation: Students undertaking clinical courses are required to be IMMUNE TO TUBERCULOSIS and HEPATITIS B and to be HEPATITIS ANTIGEN FREE PRIOR TO THEIR ARRIVAL. You must provide WRITTEN PROOF of this fact for inspection by the OCCUPATIONAL HEALTH DEPARTMENT of the Academy before entering any clinical area. These documents should be written in English. If you fail to produce the above documentation, you will be required to have a blood test, the results of this test will take a few days to come through and this will result in your elective attachment being delayed. I enclose an Immunisation Record Form, which you must read carefully, complete and return to me with your Acceptance Form. Please keep a copy to take with you to the Occupational Health Department on the first day of your attachment. Appointment details to follow. Occupational Health can be found in the Whitefriars Centre, Lewins Mead, Bristol.

2 First Day of your Attachment: On your first day (To be confirmed), please report to the Occupational Health Department as detailed above. On leaving the department, please make your way to this office; we are situated on the 2 nd floor of Dolphin House, in the King Edward Building.. Useful travel information can be found at: BRISTOL ROYAL INFIRMARY Elective students contact: Sue Bamford (Kate Walter) 2 nd Floor, Dolphin House King Edward Building Tel: To access Dolphin House: Enter the King Edward Building and turn immediately right. Go up two steps to see the door to Dolphin House. Press the top button of the group of three entry phone buttons (labelled University Psychiatry) and await response. If someone else lets you into the building, follow the signs on the walls to Kate s office.

3 Application for a Visiting Student Unit University of Bristol Medical School Name of Hospital: Dates Attending: No. of Weeks Attending (Please print in capitals) SURNAME : OTHER NAMES IN FULL : TITLE: Mr, Miss, Ms, Dr Date of Birth Sex NATIONALITY: PASSPORT NUMBER (if not EU citizen): ADDRESS: CORRESPONDENCE ADDRESS

4 NAME & ADDRESS OF MEDICAL SCHOOL BRIEF SUMMARY OF CLINICAL EXPERIENCE TO DATE DATES OF FINAL YEAR OF STUDY EXPECTED DATE OF QUALIFYING IN MEDICINE: NAME OF PARENT/GUARDIAN/NEXT OF KIN: CONTACT TELEPHONE PERMANENT HOME ADDRESS: I can provide written evidence that I am IMMUNE TO TUBERCULOSIS and HEPATITIS B and to be HEPATITIS ANTIGEN FREE. This will need to be made available to the OCCUPATIONAL HEALTH DEPARTMENT of the academy before entering any clinical area. I understand that I will be responsible for my living and accommodation costs while undertaking the Visiting Student Unit. Non EU Students: I understand that if I fail to report to my Academy on my first day of study or I am absent from teaching for over 10 days or I am absent from teaching without informing my Academy the University of Bristol will inform the Department of Immigration and Border Control of my non attendance. SIGNATURE OF APPLICANT: DATE:.

5 You must enclose a signed letter from a member of the academic staff of your university which states that support is given to you for your application for a Visiting Student Unit at Bristol University. This must be typed on official university letter headed paper and signed. Copies are not acceptable. Please supply here the name and address of your referee:

6 Name of applicant: SUPPORTING STATEMENT FROM DEAN OF HOME MEDICAL SCHOOL or DESIGNATED AUTHORITY: (This should be in addition to one separate official letter of recommendation from your Medical School) * please delete whichever is not applicable The above named applicant is of good standing in this Medical School. Yes / No* The above named applicant is competent in spoken and written English. Yes / No* The above named applicant has no criminal record. Yes / No* The above named applicant has been tested for Hepatitis B. He / she carries no hepatitis B antigen and has immunity to Hepatitis B as indicated by his / her antibody titre. Yes / No* The above named candidate will be in his/her final year of study at the time of the proposed period of the Visiting Student Unit. Yes / No* The Visiting Student Unit will / will not * need a report from an agent of Bristol university as well as the certificate of completion. ECTS credit points are needed / not needed *. The details recorded by the applicant in this application form are correct as far as I am aware Yes / No* Signed: UNIVERSITY STAMP over this area. Name: Position in Medical School: PLEASE RETURN THIS FORM TO: Sue Bamford Undergraduate Administrator Bristol South Academy Dolphin House Bristol Royal Infirmary, Bristol BS2 8HW

7 Request for Endorsement of Visiting Student Unit Name of Student This student is EU citizen or non EU. This student is in their Final Year of Study. Yes/No Name of Supervisor Specialty Hospital Academy Telephone Specific Dates Student Attending No. of Weeks Attending Description of Activities. Please attach a weekly timetable. I agree to provide supervision for the above student. I agree to inform the CfME of the students arrival/non arrival, or if the student fails to attend for a period of 10 days. Signature of Academy Medical Dean: For completion by International Office (if required) Endorse teaching proposed Yes/No/NA for non EU student. For completion by International Officer (if required) Endorse attendance of student who is not in their final year of study. Student Entered on SITS. Yes/No The University of Bristol reserves the right to refuse any application for a student to enrol on a Visiting Student Unit. (or words to that effect).

8 Dr. G.W.Tobin MD, FRCPI, FRCP, Cert.Med.Ed. South Bristol Academy Academy Medical Dean 2 nd Floor Dolphin House Bristol Royal Infirmary Miss Sheena Tranter FRCS Bristol BS2 8HW Deputy Academy Dean Telephone: (0117) /2256 Dr. Kate Reading MBBS, MSc (TLHP), MRCP Deputy Academy Dean Occupational Health Requirements for students visiting the Medical Academies of Bristol University Medical School Because of the nature of the clinical work you will be doing, the Medical Faculty requires you to be protected against those infectious diseases from which you may be at risk and against which satisfactory protection is available. You should complete this form and return it with your acceptance of the placement offer. PLEASE NOTE; Official certification of immunisation / vaccination will need to be provided on arrival for inspection by the occupational health department. Additional or repeat testing may be carried out by the Occupational Health Unit of the hospital in which you are working. See * below. Name:...Date of Birth: Contact Address:... Serological / Immunological Test / Vaccination POLIOMYELITIS immunisation Date of Certification TETANUS immunisation DIPHTHERIA immunisation RUBELLA immunisation or serological test for immunity HEAF or MANTOUX TEST confirming immunity to tuberculosis BCG if needed VARICELLA immunisation or serological test for immunity HEPATITIS B antigen serology confirmed as negative HEPATITIS B immunity confirmed as positive * HEPATITIS C antibody confirmed as negative (only if Exposure Prone Procedures to be undertaken) * HIV confirmed as negative (only if Exposure Prone Procedures to be undertaken) Additional information.. Signed:..Date:.. Academy Manager: Suzan Fowweather Suzan.Fowweather@UHBristol.nhs.uk Academy Undergraduate Administrators: Sue Bamford Sue.Bamford@UHBristol.nhs.uk; Philip Collings Philip.Collings@UHBristol.nhs.uk

9 INFORMATION FOR STUDENTS * In addition to the information you have provided you may be required to undergo additional or repeat serological testing and/or immunisation by the Occupational Health Unit (OHU) of the NHS Trust where you are undertaking your placement. This may depend on the type of clinical work you carry out and whether it includes Exposure Prone Procedures. This is in line with UK Dept of Health guidelines. Students involved in direct patient contact - no EPP. All Students involved in direct patient contact must comply with the following immunisation requirements. You must have been vaccinated against Hepatitis B and be able to provide proof of immunity i.e. a laboratory result showing an antibody titre level of 100 iu/mi or more. No student will be accepted for an elective placement unless they have previously been vaccinated against Hepatitis B. If you have been vaccinated but not checked for immunity, the OHU will carry out serological testing for surface antibody and antigen. A copy of the result(s) will be given to you, and you should keep this safely for future reference. You must have been vaccinated against Tuberculosis and have a visible BCG scar of 4 mm or greater. If not, a Heaf test may be done. If negative and there are no contraindications, you may be vaccinated with BCG and given a record of the vaccination. You should provide evidence of immunity to rubella and varicella. If you have never been tested, or have no access to testing facilities the OHU will carry out serological testing. A copy of the result(s) will be given to you. Should you require vaccination this may be done by the OHU and you should be given a record of the immunisation. You should be up to date with immunisations against Diphtheria and Tetanus All students involved in direct patient contact - EPP involved Immunisation requirements are as above. In addition you should have been tested for Hepatitis B surface antigen, Hepatitis C antibody and HIV. Even if the tests done in your home country are negative you will have to have repeat testing on arrival by the OHU. If you suspect or know that you are Hepatitis B surface antigen positive, Hepatitis C antibody positive or HIV positive, further testing may be required and you will not be allowed to participate in EPP until these tests have been carried out. Exposure Prone Procedures Exposure Prone procedures (EPP) are defined as invasive procedures where there is a risk that injury to the worker my result in the exposure of the patient's open tissues to the blood of the worker (bleed back). These include procedures where the worker's gloved hands my be in contact with sharp instruments, needle tips or sharp tissues (e.g. spicules of bone or teeth) inside a patient's open body cavity, wound or confined anatomical space where the hands or fingertips may not be completely visible at all times. Example of EPP work includes dentistry, obstetrics, and surgery. Examples of procedures that are not EPP include venepuncture, minor surface suturing, routine rectal or vaginal examinations, simple endoscopic procedures, setting up IV or central lines where the tunnelling does not involve the operators fingers being concealed within the patient in the presence of a sharp instrument. Academy Manager: Suzan Fowweather Suzan.Fowweather@UHBristol.nhs.uk Academy Undergraduate Administrators: Sue Bamford Sue.Bamford@UHBristol.nhs.uk; Philip Collings Philip.Collings@UHBristol.nhs.uk