Completed forms

and templates
Contents
The forms and templates in this pack are examples of how a nurse or midwife
may record how they meet the requirements of revalidation. These include real
life examples taken from nurses or midwives who have already revalidated.

This is not a sample portfolio of one individual nurse or midwife. The pack
includes a variety of forms and templates, designed to reflect multiple practice
settings and different ways of approaching the process.

1. Practice hours log

Secondary care - Dual registered nurse and midwife 3
University – Nursing lecturer 4
Primary care - Practice nurse 5

2. Continuing professional development log

Secondary care – Staff nurse 6

3. Feedback log
Secondary care – Midwife 8

4. Reflective accounts form (mandatory)

Community – District nurse 10
Community – Health visitor 12
Cosmetic sector – self-employed aesthetic nurse 14

5. Reflective discussion form (mandatory)

Care home – Staff nurse 16

6. Confirmation form (mandatory)

Care home – Staff nurse 17

The reflective accounts, reflective discussion and confirmation forms are all
mandatory for revalidation.
 Guide to completing practice hours log Work setting • Maternity unit or birth centre Scope of practice 1, 2
• Military • Direct clinical care
To record your hours of practice as a registered nurse, • Ambulance service
• Occupational health • Education
midwife and nursing associate, please fill in a page for • Care home sector
• Police • Research
each of your periods of practice. Please enter your most • Community setting (including
• Policy organisation • Management
district nursing and community
recent practice first and then any other practice until you
psychiatric nursing) • Prison • Leadership
reach 450 hours. You can only count practice hours during
Consultancy • Private domestic setting • Policy
•
the three year period since your last registration renewal or Cosmetic or aesthetic sector • Public health organisation • Commissioning
•
initial registration. You do not necessarily need to record • School • Consultancy
• Governing body or other
individual practice hours. You can describe your practice leadership • Specialist or other tertiary care • Quality assurance or inspection
hours in terms of standard working days or weeks. For GP practice or other primary including hospice
• Registration
example if you work full time, please just make one entry care • Telephone or e-health advice
• Trade union or professional • Registered Nurse
of hours. If you have worked in a range of settings please • Hospital or other secondary • Midwife
care body
set these out individually. You may need to print additional • Nursing Associate
• Inspectorate or regulator • University or other research
pages to add more periods of practice. If you are both a facility • Registered Nurse/SCPHN
nurse and a midwife or a nursing associate and nurse you • Insurance or legal
• Voluntary or charity sector • Midwife/SCPHN
will need to provide information to cover 450 hours of • Other Registered Nurse and
practice for each of these registrations. Midwife (including
Registered Nurse/SCHPN
and Midwife/SCPHN)

Dates: Name and Your work Your scope Number Your Brief description of your work:
address of setting of practice of hours: registration
organisation: (choose from list above): (choose from list above): (choose from list above):

1 The Code (NMC 2018) https://www.nmc.org.uk/standards/code/

2 Standards of proficiency for: registered nurses (NMC 2018), nursing associates (NMC 2018) and midwives (NMC 2019): https://www.nmc.org.uk/standards/
Page 3 of 19
10/12/2010 London Hospital, Hospital Direct patient Full time 37.5 Nurse and Midwife on labour and PN ward, also rely
– Current London Road, care hours per week midwife on nursing skills, knowledge &
London. experience every day. Caring for women
and babies in labour and postpartum
period; caring for women post-
operatively; CTG monitoring; suturing;
breastfeeding support; examination of
the new born.

Page 4 of 19
 Guide to completing practice hours log Work setting • Maternity unit or birth centre Scope of practice 3, 4
• Military • Direct clinical care
To record your hours of practice as a registered nurse, • Ambulance service
• Occupational health • Education
midwife and nursing associate, please fill in a page for • Care home sector
• Police • Research
each of your periods of practice. Please enter your most • Community setting (including
• Policy organisation • Management
recent practice first and then any other practice until you district nursing and community
psychiatric nursing) • Prison • Leadership
reach 450 hours. You can only count practice hours during • Private domestic setting
• Consultancy • Policy
the three year period since your last registration renewal or • Public health organisation
• Cosmetic or aesthetic sector • Commissioning
initial registration. You do not necessarily need to record • School
• Governing body or other • Consultancy
individual practice hours. You can describe your practice • Specialist or other tertiary care • Quality assurance or inspection
leadership
hours in terms of standard working days or weeks. For including hospice
• GP practice or other primary Registration
example if you work full time, please just make one entry of care • Telephone or e-health advice
hours. If you have worked in a range of settings please set • Trade union or professional • Registered Nurse
• Hospital or other secondary • Midwife
these out individually. You may need to print additional care body
• University or other research • Nursing Associate
pages to add more periods of practice. If you are both a • Inspectorate or regulator
facility • Registered Nurse/SCPHN
nurse and a midwife or a nursing associate and nurse you • Insurance or legal
• Voluntary or charity sector • Midwife/SCPHN
will need to provide information to cover 450 hours of Registered Nurse and
• Other
practice for each of these registrations. Midwife (including
Registered Nurse/SCHPN
and Midwife/SCPHN)

Dates: Name and Your work Your scope Number Your Brief description of your work:
address of setting of practice of hours: registration
organisation: (choose from list above): (choose from list above): (choose from list above):

June 2013 – Norwich University Education 1600 hrs per year Nurse Teaching pre-registration nurses, and
June 2016 University, teaching post qualifying courses at under
Norwich Road, and post graduate level.
Norwich. Link lecturer, practice liaison and
associated activities, marking.

3 The Code (NMC 2018) https://www.nmc.org.uk/standards/code/

4 Standards of proficiency for: registered nurses (NMC 2018), nursing associates (NMC 2018) and midwives (NMC 2019): https://www.nmc.org.uk/standards/
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 Guide to completing practice hours log Work setting • Maternity unit or birth centre Scope of practice 5, 6
• Military • Direct clinical care
To record your hours of practice as a registered nurse, • Ambulance service
• Occupational health • Education
midwife and nursing associate, please fill in a page for each • Care home sector
• Police • Research
of your periods of practice. Please enter your most recent • Community setting (including
• Policy organisation • Management
practice first and then any other practice until you reach 450 district nursing and community
psychiatric nursing) • Prison • Leadership
hours. You can only count practice hours during the three • Private domestic setting
• Consultancy • Policy
year period since your last registration renewal or initial • Public health organisation
• Cosmetic or aesthetic sector • Commissioning
registration. You do not necessarily need to record • School
• Governing body or other • Consultancy
individual practice hours. You can describe your practice • Specialist or other tertiary care • Quality assurance or inspection
leadership
hours in terms of standard working days or weeks. For
GP practice or other primary including hospice
• Registration
example if you work full time, please just make one entry of care • Telephone or e-health advice
hours. If you have worked in a range of settings please set • Trade union or professional • Registered Nurse
• Hospital or other secondary • Midwife
these out individually. You may need to print additional care body
• University or other research • Nursing Associate
pages to add more periods of practice. If you are both a • Inspectorate or regulator
facility • Registered Nurse/SCPHN
nurse and a midwife or a nursing associate and nurse you • Insurance or legal
• Voluntary or charity sector • Midwife/SCPHN
will need to provide information to cover 450 hours of Registered Nurse and
• Other
practice for each of these registrations. Midwife (including
Registered Nurse/SCHPN
and Midwife/SCPHN)

Dates: Name and Your work Your scope Number Your Brief description of your work:
address of setting of practice of hours: registration
organisation: (choose from list above): (choose from list above): (choose from list
above):

5 The Code (NMC 2018) https://www.nmc.org.uk/standards/code/

6 Standards of proficiency for: registered nurses (NMC 2018), nursing associates (NMC 2018) and midwives (NMC 2019): https://www.nmc.org.uk/standards/
Page 6 of 19
6 January Heatherfield GP GP practice Direct patient 12 hours per Nurse Part of primary healthcare team, with duties
2008 - Practice, Leeds care week = approx. including:
Current Road, Leeds. 560 hours per - Venepuncture
year - Travel health advice and vaccinations
- Smoking cessation
- Family planning & women’s health

Page 7 of 19
 Guide to completing CPD record log
Examples of learning What was the topic? Link to Code Link to Standards of proficiency
method Please give a brief outline of the key points Please identify the part or parts of the Code Please identify the part or parts of the
• Online learning of the learning activity, how it is linked to relevant to your CPD. relevant standards that you used to inform
• Course attendance your scope of practice 7, 8, what you learnt, • Prioritise people your CPD
• Independent learning and how you have applied what you learnt • Practise effectively
to your practice. • Preserve safety
• Promote professionalism and trust

Please provide the following information for each learning activity, until you reach 35 hours of CPD (of which 20 hours must be participatory). For examples of the types of CPD activities you could
undertake, and types of evidence you could retain, refer to our guidance sheet at www.revalidation.nmc.org.uk/download-resources/guidance-and-information.

Dates: Method: Topic(s): Link to Code: Link to Number of Number of

Please describe the methods you Standards of hours: participatory
used for the activity: proficiency: hours:

7 The Code (NMC 2018) https://www.nmc.org.uk/standards/code/

8 Standards of proficiency for: registered nurses (NMC 2018), nursing associates (NMC 2018) and midwives (NMC 2019): https://www.nmc.org.uk/standards/
Page 8 of 19
4.4.14 Independent learning – Clinical mandatory training Practise Being an 7.5 0
online course Update for all clinical aspects relevant effectively accountable
to my role, including blood transfusion, Preserve professional
manual handling and safeguarding. safety
Improving safety
Some of what we covered I already
and quality
knew, but it was good to refresh. I
of care
learned that there was a new blood
transfusion policy and a new procedure
for collecting blood from the fridge. I
haven’t done this in practice for a while
so it was important that I learnt this.

27.5.14 Course attendance IV Therapy. This course enabled me Practise Assessing needs 7.5 7.5
to learn the theory and practice effectively and planning
behind IV therapy. Also got to practise Preserve care
aseptic non touch technique (ANTT). I
have increased my knowledge and safety
providing and
am now able to deliver IV therapy
safely. evaluating
care

3.6.201 Independent learning – Caring for people who are dying: Prioritise Being an 2 0
5 reading article priorities at the end of life. Read people accountable
CPD article in Nursing Standard. professional
Gained new ideas which I will reflect
on and discuss with my team, with a Improving safety
view to making changes to our
practice. and quality
of care

Page 9 of 19
16.6.14 Meeting attendance Mentor update. Face to face Prioritise Being an 3 3
session which informed me of recent people accountable
changes to student nurse training professional
and reminded me of the standards I
need to achieve as a mentor. Improving safety
Allowed me to reflect on my role as a
mentor and role model to students in and quality
the last six months. of care

1.3.16 Conference attendance RCN Education Conference. Practise Improving safety 15 15

Attended two-day conference. effectively and quality
Presentations on quality surgical Preserve of care
nursing and its impact on clinical
practice were particularly relevant to safety
Leading and
me. I will present these ideas to the
team at our next meeting, and have Managing Nursing
gained some ideas on implementing care and
more training in my area. Working in
teams

Total: 35 Total: 25.5

Page 10 of
Guide to completing a feedback log Examples of sources of feedback Examples of types of feedback
Please provide the following information for each of • Patients or service users • Verbal
your five pieces of feedback. You should not record • Colleagues – nurses midwives, other • Letter or card
any information that might identify an individual, healthcare professionals • Survey
whether that individual is alive or deceased. • Students • Report
Guidance Sheet 1 in How to revalidate with the • Annual appraisal
NMC provides guidance on how to make sure that • Team performance reports
your notes do not contain any information that might • Serious event reviews
identify an individual.

You might want to think about how your feedback

relates to the Code, and how it could be used in
your reflective accounts.

Source of feedback Type of feedback

Date Content of feedback
Where did this feedback How was the feedback
What was the feedback about and how has it influenced your practice?
come from? received?

The student found it valuable when I let her take the lead in a
1.7.2015 Student Verbal, in a meeting to review postnatal baby check. I will encourage my students to take the lead
placement documentation more often and try to only provide direction when they need it.
Linked to ‘promote professionalism and trust’ in the Code.

Thanking me for supporting her and her partner throughout the

Woman I looked after on PN Thank you letter discharge process. Highlighted the importance of taking time to make
10.8.2015 ward sure women feel confident and comfortable before they are sent
home with their new baby. Linked to ‘prioritise people’ in the Code.

Page 11 of
 Gave me feedback on my leadership style. We discussed what works
12.11.2015 Annual appraisal Verbal well, and areas where I could improve. We also talked about a
leadership course which I am going to attend next month.

A complaint was received about the ward, from a woman who felt she
3.2.2016 Patient Written complaint received poor care, inadequate support with breastfeeding and was
not kept in the loop about discharge process. Will reflect on this in one
of my reflective accounts. Linked to ‘prioritise people’ in the Code.
I asked a more experienced midwife on the ward to observe a
7.5.2016 Colleague Verbal breastfeeding support session I lead, and give me feedback. We
talked about what I did well, and some new ideas and techniques I
could include in my session. Will reflect on this in one of my reflective
accounts.

Page 12 of
You must use this form to record five written reflective accounts on your CPD and/or practice-related feedback
and/or an event or experience in your practice and how this relates to the Code. Please fill in a page for each
of your reflective accounts, making sure you do not include any information that might identify a specific
patient, service user or colleague. Please refer to our guidance on preserving anonymity in Guidance sheet 1
in How to revalidate with the NMC.

Reflective account: Community – District nurse

What was the nature of the CPD activity and/or practice-related feedback
and/or event or experience in your practice?

CPD participatory activity. Attending a Manual Handler Transfer Specialist course.

What did you learn from the CPD activity and/or feedback and/or event or
experience in your practice?

As an experienced community nurse I have had to adapt to various environments to deliver

care safely and effectively. Working within the community team we provide care for patients
with complex health care needs at home, most presenting with limited ability to mobilise
and transfer independently. I participated in the manual handling transfer specialist training
course to develop the team’s knowledge and skills in patient handling. The role of transfer
specialist will also promote the team’s compliance with the Trust’s mandatory training
programme.
The statistics highlighting that 24% of NHS staff are injured through poor manual handling
practice, and that poor practice contributes to 40% of sickness and absence, emphasise the
need for raising awareness of the consequences of poor practice. The cost to the NHS for
compensation claims is approximately £150 million a year; money that should go directly to
patient care.
The role of transfer specialist will focus on organisational and individual training needs to
move safer handling practice forward across the organisation, in line with current best
practice. Each trainer will be expected to attend a minimum of one update training session
every year facilitated by a board manual handling advisor.
Staff will complete a structured manual handling passport and will be assessed carrying out
practical modules relevant to their workplace. For new staff an induction will be carried out
and a checklist of training needs must be met prior to commencement of work. Self-
assessments will be carried out every two years and, if required, training will be provided by
the transfer specialist.
The legislation regarding risk assessments and safety at work was discussed and the
importance of assessment prior to performing any task was reinforced, with the aim to
reduce risk of injury to both patient and staff member.

Page 10 of 19
How did you change or improve your practice as a result?

We have arranged a teaching programme which includes individual task assessments,

control measures, risk assessments, care plans and review dates. We have offered to
accompany colleagues on home visits to carry out complex assessments, enabling us to
initiate safer handling principles. We will act as a resource to the team in relation to the
ordering of equipment, with the purpose of reducing the risk of injury to colleagues and
patients as a result of poor manual handling practice.

How is this relevant to the Code?

Select one or more themes: Prioritise people – Practise effectively – Preserve safety – Promote
professionalism and trust

All four themes of the NMC Code are linked to this CPD activity:
Prioritise people - the majority of people referred to the CRT are older with chronic
limitations including social needs. For some patients to remain at home safely, functional
assessments are necessary to perform the fundamentals of care safely. The extended
knowledge and skills in identifying appropriate aids for transferring patients enables them to
remain independent with formal support at home.
Practise effectively – the ongoing manual handling updates enables staff members to
maintain the knowledge and skills needed for safe and effective practice.
Preserve safety – As a transfer specialist I am to be a resource for the team, supporting
colleagues to take account of their own personal safety as well as patient safety by
attending manual handling training sessions.
Promote professionalism and trust - I intend to be a model of integrity and leadership by
being committed to the standards of safer handling practice.

Page 11 of 19
You must use this form to record five written reflective accounts on your CPD and/or practice-related feedback
and/or an event or experience in your practice and how this relates to the Code. Please fill in a page for each of
your reflective accounts, making sure you do not include any information that might identify a specific patient,
service user or colleague. Please refer to our guidance on preserving anonymity in Guidance sheet 1 in How to
revalidate with the NMC.

Reflective account: Community – Health visitor

What was the nature of the CPD activity and/or practice-related feedback
and/or event or experience in your practice?
I received written feedback on a record keeping and documentation and train the
trainer training day that I delivered with a colleague. The audience included health
visitors, student health visitors and managers. The organisation was in the process
of moving to a new record keeping system and had concerns about the quality of
their practitioner’s records. There had been a number of serious case reviews
where poor record keeping was highlighted as a contributing factor. My colleague
and I delivered the record keeping session and I delivered the train the trainer
session. Feedback was received from participants who completed an evaluation
form. I also received a thank you email from the manager who commissioned the
session.

What did you learn from the CPD activity and/or feedback and/or event or
experience in your practice?

The feedback from participants was positive and demonstrated that expectations of
the session had been met. The content, materials and delivery of the session were
rated excellent or very good, indicating it had been well received and was beneficial.
There were a number of additional comments. It was suggested there could have
been more focus on the how participants themselves could deliver the training,
more on the basics of record keeping in relation to current NMC guidelines and,
rather than maintaining the same members of a group within the different interactive
sessions, it would have been beneficial if members were moved around.

I was pleased with the feedback, in particular the additional comments from
participants that would enable me to improve future sessions.

Page 12 of 19
How did you change or improve your practice as a result?

I reviewed the training package based on the feedback provided and the
programme for future sessions was amended, addressing the suggestions made.

How is this relevant to the Code?

Select one or more themes: Prioritise people – Practise effectively – Preserve safety – Promote
professionalism and trust

It is relevant to the theme ‘prioritise people’ in terms of listening to people and

responding to their preferences and concerns. I had a number of meetings and
communications with the management team and representatives to ensure the
training day would meet their requirements, and I made changes based on the
feedback received.

It is also relevant to the themes ‘practise effectively’ and ‘promote professionalism

and trust’ in terms of practising in line with the best available evidence, working
cooperatively, communicating clearly, and sharing skills and knowledge. It was
important that the best available evidence was used in the presentation, which
required me to research the subject area and ensure I was confident in my
knowledge. I also had to ensure that I communicated clearly and varied the
teaching methods to facilitate participants’ engagement, recognising that people
learn in different ways. The session encouraged participants to uphold the
standards and values set out in the Code.

Page 13 of 19
You must use this form to record five written reflective accounts on your CPD and/or practice-related feedback
and/or an event or experience in your practice and how this relates to the Code. Please fill in a page for each of
your reflective accounts, making sure you do not include any information that might identify a specific patient,
service user or colleague. Please refer to our guidance on preserving anonymity in Guidance sheet 1 in How to
revalidate with the NMC.

Reflective account: Cosmetic sector – self-employed aesthetic nurse

What was the nature of the CPD activity and/or practice-related feedback
and/or event or experience in your practice?

• An experience from a clinic treatment day, during the pre-treatment

discussion with a patient.
• When I asked if there were any changes to medical or drug history, the
patient said there had been no changes. T
• Patient did not consider that taking oral low dose aspirin was a medical or
drug related issue, and therefore did not inform us that six weeks ago she’d
commenced prophylactic oral low dose aspirin after reading an article in a
newspaper.
• This resulted in her subsequent bleeding during the elective procedure which
had to be abandoned.

What did you learn from the CPD activity and/or feedback and/or event or
experience in your practice?

• Learnt that patients do not always have a clear understanding of the

information we are requesting from them.
• I reflected on how we asked patients for general information - it is quite
possible that patients do not consult with Health Care Professionals when
making choices - in this case they read an article, purchased an OTC
medication and commenced self-medication.
• This highlights that patients may not consider self-medication either a
‘medical’ or ‘drug’ change and therefore would not report a change to us.

How did you change or improve your practice as a result?

• Reviewed the written information we give to patients prior to treatment

• Introduced a risk assessment for bruising
• This risk assessment includes a list of possible medications they may be
taking and might not think to mention, such as low dose Aspirin, Vitamin E
supplements, cod liver oil capsules etc.

Page 14 of 19
How is this relevant to the Code?
Select one or more themes: Prioritise people – Practise effectively – Preserve safety – Promote
professionalism and trust

This is relevant to all principles of the Code, but in particular:

• Practising effectively – this experience is about communicating clearly, and
taking steps to ensure people understand what is being asked of them.
• Preserving safety – I took steps to reduce as far as possible any potential for
harm associated with my practice by introducing a new risk assessment for
bruising.

Page 15 of 19
 You must use this form to record your reflective discussion with another NMC-registered nurse or midwife
about your five written reflective accounts. During your discussion you should not discuss patients, service
users or colleagues in a way that could identify them unless they expressly agree, and in the discussion
summary section below make sure you do not include any information that might identify a specific patient or
service user. Please refer to Guidance sheet 1 in How to revalidate with the NMC for further information.

To be completed by the nurse or midwife:

A.Nurse
Name:

12A1234B
NMC Pin:

To be completed by the nurse or midwife with whom you had the discussion:

L. Manager
Name:

13A1234B
NMC Pin:

[email protected]
Email address:

Professional address including London

postcode: Hospital
Jones Road
London
LN1 2NM
020 1232 1234
Contact number:

30/01/2016
Date of discussion:

Short summary of discussion: We discussed all five of Amy's reflective

accounts and linked them back to the Code. We
had a very beneficial discussion about some of
the issues raised, and shared our different
perspectives. We also identified some
professional development objectives for Amy,
and she is now going to write an action plan for
the future.

Page 16 of 19
I have discussed five written Signature:
reflective accounts with the named
nurse, midwife or nursing associate as
part of a reflective discussion.
I agree to be contacted by the NMC to
provide further information if
necessary for verification purposes.
Date: 30/01/2016

Page 17 of 19
You must use this form to record your confirmation.

To be completed by the nurse, midwife or nursing associate:

Name: A.Nurse

NMC Pin: 12A1234B

Date of last renewal of registration or

01/01/2013
joined the register:

I have received confirmation from (select applicable):

x A line manager who is also an NMC-registered nurse, midwife or nursing associate

A line manager who is not an NMC-registered nurse, midwife or nursing associate

Another NMC-registered nurse, midwife or nursing associate

A regulated healthcare professional

An overseas regulated healthcare professional

Other professional in accordance with the NMC’s online confirmation tool

To be completed by the confirmer:

Name: L.Manager

Job title: Ward Manager

Email address: [email protected]

Professional address London

including postcode: Hospital
Jones Road
London
LN1 2NM
Contact number: 020 1232 1234

Date of confirmation discussion: 30/01/2016

If you are an NMC-registered nurse, midwife or nursing associate please provide:

Page 18 of 19
NMC Pin: 13A1234B

If you are a regulated healthcare professional please provide:

Profession: Nurse

Registration number for regulatory body: 13A1234B

If you are an overseas regulated healthcare professional please provide:

Country:

Profession:

Registration number for regulatory body:

If you are another professional please provide:

Profession:

Registration number for regulatory body (if relevant):

Confirmation checklist of revalidation requirements

Practice hours

You have seen written evidence that satisfies you that the nurse, midwife or nursing associate
x
has practised the minimum number of hours required for their registration

Continuing professional development

You have seen written evidence that satisfies you that the nurse, midwife or nursing associate has
x
undertaken 35 hours of CPD relevant to their practice as a nurse, midwife or nursing associate

You have seen evidence that at least 20 of the 35 hours include participatory learning relevant to their
x practice as a nurse, midwife or nursing associate. You have seen accurate records of the CPD
undertaken.

Practice-related feedback

You are satisfied that the nurse, midwife or nursing associate has obtained five
x pieces of practice-related feedback.

Page 19 of 19
Written reflective accounts
You have seen five written reflective accounts on the nurse, midwife or nursing associate’s CPD
x and/or practice-related feedback and/or an event or experience in their practice and how this relates
to the Code, recorded on the NMC form.

Reflective discussion

You have seen a completed and signed form showing that the nurse, midwife or nursing
x
associate has discussed their reflective accounts with another NMC-registered individual(or
you are an NMC-registered individual who has discussed these with the nurse, midwife or
nursing associate yourself).

I confirm that I have read Information for confirmers, and that the above named NMC-
registered nurse, midwife or nursing associate has demonstrated to me that they have
met all of the NMC revalidation requirements listed above during the three years since
their registration was last renewed or they joined the register as set out in Information for
confirmers.

I agree to be contacted by the NMC to provide further information if necessary for verification
purposes. I am aware that if I do not respond to a request for verification information I may put
the nurse, midwife or nursing associate’s registration application at risk.

Signature:

Date: 30/01/2016

Page 20 of 19
I
Page 21 of 19