v5 Notification of practice form (NoP) Name: Pin: Expiry: Employer Name: _______________________________________________________ NHS Other Directions If you want to renew your registration please complete all sections of steps 1, 2 and 3. If you want to lapse your registration please only complete step 4. Failure to complete the required sections of this form will delay the renewal of your registration. Please mark the boxes with a clear ✗ and use the attached notes to help you complete this form correctly. 1 Step 1: Renewing registration Indemnity Arrangement I declare that I hold, or will hold when I begin practising, appropriate cover under an indemnity arrangement in relation to my practice, and will be able to provide evidence to support this if required by the NMC. Yes Continued Professional Development (CPD) I declare I have undertaken at least 35 hours of learning activity relevant to my practice during the last three years and will be able to provide evidence to support this if required by the NMC. Yes Prep Practice I declare by placing an ✗ in the relevant boxes that I have undertaken the required hours of registered practice as indicated below in the last three years and I have evidence to support this if required by the NMC. Nursing - 450 hours Yes Midwifery - 450 hours Yes Nursing and specialist community public health nursing - 450 hours Yes Midwifery and specialist community public health nursing - 900 hours Yes If you have declared practice as a midwife or as a midwife and specialist community public health nurse in the UK then an Annual Intention to Practise (ItP) form must have been filed with your LSAMO. See attached notes for further information on this. 2 Step 2: Police charges, cautions or convictions Charge, caution or conviction Have you received a police charge, caution or conviction since 1 August 2004 other than a protected caution and conviction? If yes, you must also complete step 5. No Yes Please do not notify the NMC of: motoring offences where you received a fixed penalty (unless it led to a disqualification of driving) or offences that have previously been considered by the NMC. 3 Step 3: Declaration Please sign and date I declare that my health and character are sufficiently good to enable me to practise safely and effectively as demonstrated in the Code and that all of the above information is a true and accurate statement. Signature: Date: Please note that any information you provide about yourself will be used in accordance with NMC’s Data privacy policy, which is available on our website www.nmc-uk.org. Please turn over July14 v5 Name: 4 Pin: Step 4: Lapsing your registration Please sign and date only if you wish to LAPSE your registration If you DO NOT want to renew your registration then sign and date the declaration below and return to the NMC. I want to LAPSE my registration and can confirm that I am not aware of any matter which could give rise to a fitness to practise allegation against me. Signature: 5 Date: Step 5: Police charges, cautions or convictions statement If you answered YES in Step 2 please provide this additional information In addition to your Notification of practice form and your registration fee you will need to provide the following information: • A statement detailing a clear account of the circumstances that led to the offence. • A copy of any relevant paperwork received by the police, DVLA or court services. • A character reference, on headed paper, signed by your employer confirming their awareness of the offence and commenting on your fitness to practise. • A reference from your GP which must declare that there is no history of alcohol or drug related illness in your records, if you are declaring an alcohol or drug related offence. . • Any other information you feel is relevant to the offence that you wish to be considered. Please use the box below to provide a detailed statement of the incident(s) you are declaring. Please refer to the guidance notes for information on protected cautions and convictions. Please contact our Registrations centre on 020 7333 9333 if you need assistance. ______________________________________________________________________________________________________ ______________________________________________________________________________________________________ ______________________________________________________________________________________________________ ______________________________________________________________________________________________________ ______________________________________________________________________________________________________ ______________________________________________________________________________________________________ ______________________________________________________________________________________________________ ______________________________________________________________________________________________________ ______________________________________________________________________________________________________ ______________________________________________________________________________________________________ ______________________________________________________________________________________________________ ______________________________________________________________________________________________________ ____________________________________________________________________ NOP Ver 5 (07/14) Please continue on a separate sheet if needed.