HWNZ Application Form 2013 - Nelson Marlborough District Health ...

Instructions
NZNC Registration Number * :
Best Contact Phone Number * :
Best Contact Email Address * :
2nd Email Address:
If no please indicate the hours you expect to work in 2013 * :
Clinical area of practice/specialty*: HWNZ Defined
DHB ( Nelson or Wairau ) * :
Clinical area of practice/specialty: HWNZ Defined
Full Postal address i.e. P O Box address:
Section C. Postgraduate Qualification Level 2013
FUNDING APPLICATION
for
Postgraduate Education (HWNZ)
Nursing 2013
This form must be submitted via email. No written applications will be accepted.
Funding is for programmes of study that lead to level 8 qualifications on the National
Qualifications Framework. To check your funding accessability, please refer to the
HWNZ Policy. Also see Nursing Training Programme Specifications in the “HWNZ
Website” link below.
• This application covers the entire 2013 academic year, Semesters 1, 2, 3 (summer school)
• This is your only opportunity to gain funding for post graduate study in 2013
• Organisational support must be obtained in order to access this funding
• Please complete all relevant sections in this application form
• Note – Late applications are only considered on a case by case basis at the discretion of the
Director of Nursing.
• All applicants will be notified of the decision as soon as possible. All applications will be
reviewed by the Nursing Post Graduate Advisory Committee against the criteria for selection
and those that meet the criteria will receive a letter to approve funding.
• Enrolment with the Tertiary Education Provider is a separate process required of the
applicant. Please submit an enrolment with your tertiary education provider
• A signed Career Plan MUST be attached to this document (HWNZ requirement)
Applications close 4pm Friday, 5th October 2012
If you have questions please contact:
Sandy Matheson, Nurse Consultant Education
NMDHB, 03 539 5346 or email: sandy.matheson@nmdhb.govt.nz
Section A. Applicant Information ( * mandatory fields)
Surname * :
Preferred Surname:
Home Address * :
First Name * :
Date of Birth * : Age * :
Work phone * :
Are you a New Zealand Citizen * :
Note: If NO proof of residency is required
Some funding is also available to provide cultural and professional supervision/mentoring for Maori and Pacific trainees. Cultural &
professional supervision/mentoring required?
Section B. Employment Information
Name of Employer * : i.e. NMDHB, Hospice Marlb, Plunket, Tahuna, etc
Role Title:
FTE Worked weekly * :
Length of time in current role * : (years), e.g. 5 or 6.5 or 10 etc.
Do you expect to remain working the same hours in 2013 * :
Date of last performance review * : (dd/mm/yyyy)
PDRP/QLP Level*:
DHB Employee
DHB Directorate*:
Line Manager / CNM*
HWNZ Website
Preferred first Name:
Gender * :
Ethnicity * :
NON DHB Employee - PHO, NGO, Aged and Residential Care, Plunket, Ministry of Health Contract Providers
Iwi:

Postgraduate study must be approved by the Nursing Council of New Zealand (NCNZ) or be able to be
credited towards a NCNZ approved qualification (see link below). You must apply to your Tertiary Education
Provider for a “transfer of credit” to bring papers/courses into a NCNZ approved qualification.
Note: Please refer to the levels of Postgraduate Qualifications figure (below) before completing Tables
D and E
*If undertaking study after completing a Nursing Masters Degree please proceed to:
Section F: Post-Masters Programme
Section D. Qualification Level: List completed papers within each qualification level that builds towards your current
qualification (e.g. Postgraduate Certificate, Diploma completed)
Qualification
Postgraduate Certificate
(Level 1)
Postgraduate Diploma
(Level 2)
Postgraduate Masters Degree
(Level 3)
Paper Code
i.e. NURS518
Level of Qualification
Level 4
Level 3
Level 2
Level 1
Please refer to www.nursingcouncil.org.nz for a list of approved degree programmes
I have checked that my paper/course contributes towards the stated NCNZ approved qualification *
Will you complete this qualification in 2013? *
If NO, what year do you anticipate completion of this qualification? *
Postgraduate Masters Degree
(Level 4 -Usually final two papers of degree)
Year Paper Number
/ Code
Paper Name
Post Masters
Completing Masters Degree
Paper Length
by Semester
Semester you
wish to Study
in
Name of Paper
paper Point
Value
Thesis Dissertation:
If you are planning to undertake or are completing a research thesis, please briefly outline the topic and relevance to service.
Paper credit
value
Section E. 2013 Paper Enrollments
List papers you are enrolling in for 2013 (all semesters) NB: One you have applied, you cannot change your points value
Level Four Programme Practicum Paper
If you are planning to undertake a prescribing or non-prescribing practicum paper to complete your degree in 2013, a practicum
support plan must be prepared before commencing the paper
Are you enrolling in a prescribing or non-prescribing practicum in 2013? If
yes please contact the Nurse Consultant Education via
sandy.matheson@nmdhb.govt.nz
Papers Towards Masters Degree
Postgraduate Diploma
Postgraduate
Certificate
Programme Name - Building Towards Masters Degree
Draft Practicum Support plan completed? To access support
to prepare a Practicum Support Plan please contact your
Nurse Consultant Education /
sandy.matheson@nmdhb.govt.nz
A Practicum Support Plan will address the additional expectations of clinical teaching/preceptorship (often medical),
mentoring and professional supervision often associated with these papers. HWNZ funding subsidises some of the
additional costs associated with completing a Nurse Practitioner prescribing practicum
Section F. Post Masters Programmes of Study/Qualifications
This section asks about 2013 enrolments towards a Post-Masters programme of study/qualification
Masters Degree Qualification Name:
Grade
Tertiary Education Provider

University:
Year Conferred:
Section G. Rationale for Study & Professional Development (Career) Plan
Do you have a current professional portfolio? * Evidence of the status of your Portfolio MUST be forwarded to the
Nurse Consultant Education along with this application.
If you are a NMDHB employee you MUST be up to date with the PDRP requirements or we will not fund you. If you do not work
for the DHB but your organisation has a PDRP programme you MUST be compliant with this or we will not fund you.
Please briefly outline below how your proposed programme of study….
1, Is relevant to your work, goals and aspirations (include your area of interest):
2, Will this programme enhance your ability to contribute to nursing in your organisation:
4, Please also: Outline barriers that may prevent you from completing your proposed programme of study and actions you will take to minimise these:
Section H. Funding
Have you sought funds from other sources?
Section I. Sign Off
This form must be completed electronically and emailed with the appropriate supporting
documentation to your CNM/Team Leader/Manager who will approve and forward to the
appropriate Nurse Consultant Education for approval. A confirmation of receipt will be sent to
the applicant.
Section J. Declaration
1. I confirm that all the information supplied in support of my application is accurate at the date of signing and the supporting documentation
is enclosed
2. I declare that I have not applied for, and do not expect to receive, any funding in addition to this funding to assist with my study related costs
in the 2013 year
3. I understand that this funding is included in my overall entitlements to Professional Development Funding
4. I consent to the disclosure of the personal information given on this form to recipients for purposes related to the advancement of my studies
and as required by protocols between NMDHB and external agencies
5. I understand that as per the HWNZ Professional Development Funding Framework if I withdraw or fail a paper I may need to repay funds
allocated to me
6. I authorise and Direct any Tertiary Education provider at which I am/have been undertaking any course of study relating to this grant to
provide to Nelson Marlborough District Health Board and Health Workforce New Zealand the following information:
Full name
Relevant course completion information
Date of course completion
Outcome of course
Pass or failure to attain a pass
Withdrawal from course
Section Date and K. reason for withdrawal
This form and must be sent electronically to sandy.matheson@nmdhb.govt.nz
supporting documentation must be scanned and emailed or posted to the DONM Office
Nurse Consultant Education,
Post Graduate Education,
Nelson Marlborough District Health Board, DHB Office,
Private Bag 18, Nelson 7042
1 Paper outlines, descriptors and points download from Tertiary Education providers website: *
2 Evidence of your Professional Development and Recognition Programme (PDRP) status *
3 Copy of your academic transcript or results summary of papers/courses/programme completed (if applicable): *
4 Draft Practicum Support Plan - Level 4 Programme only (if applicable): *
5 Clinical Mentoring Support Plan (if applicable): *
6 Signed Career Plan: *
In submitting this form electronically I agree to the declarations in section J: *
Thank you