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2012 HWNZ application form (Excel)


									                                                    FUNDING APPLICATION
                                                Postgraduate Education (HWNZ)
                                                   Nursing & Midwifery 2012

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 New Zealand
Qualifications Framework. To access funds please read the Health Workforce New Zealand (HW
Postgraduate Funding Information at the link below. Also see Postgraduate Nursing Training
Specifications for background information on the Ministry of Health website (link below).

     This application covers the entire 2012 academic year, Semesters 1, 2, 3 (summer sch
     This is your only opportunity to gain funding for post graduate study in 2012
     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
      the Director of Nursing & Midwifery, Hospital and Health Service (HHS)
     All applicants will be notified of the decision as soon as possible. All applications will
      reviewed by the HWNZ Advisory Committee against the criteria for selection and those
      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 as soon a

Applications close 4pm, 2nd October 2011
If you have questions please contact:
Sheryl Hunt, Nurse Consultant, Workforce & Informatics
C&C DHB, 04 806 2390 or 027 212 5137
or email:
                                                                      HWNZ Website
Section A. Applicant Information
Surname:                                                                                      First Name:
Preferred Surname:                                                                            Preferred first Name:
NZNC/MCNZ Registration Number:                                                                Gender:
Date of birth:                                                                                Age:
Best Contact Number:                                                                          Work phone:
Best Email Address:                                                                           Ethnicity:
Home Phone Number:                                                                            Iwi:
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.
apply during the funding round.
Section B. Employment Information
Name of Employer: i.e. C&C DHB, Compass Health, Te Hopai
Role Title:
FTE Worked weekly:
Length of time in current role: (years)
Do you expect to remain working the same hours in 2012:
If no please indicate the hours you expect to work in 2012:
Date of last performance review:
DHB Employee - HHS - Hospital & Health Services
DHB Directorate:
Line Manager:
Clinical area of practice/specialty: HWNZ Defined
DHB Postal address i.e. ICU, Level 3 WRH:
NON DHB Employee - PHO, NGO, Aged and Residential Care, Plunket, Ministry of Health Contract Providers
Clinical area of practice/specialty: HWNZ Defined
Full Postal address i.e. P O Box address:
Full Postal address i.e. P O Box address:
Section C. Postgraduate Qualification Level 2012

Postgraduate study must be approved by the Nursing Council of New Zealand (NCNZ) or be able to be cre
towards a NCNZ approved qualification (see link below). You must apply to your Tertiary Education Provid
“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

*If undertaking study after completing a Nursing Masters Degree please proceed to:
Table F: Post-Masters Programme

                                                                            Post Masters

                                                                Level 4       Completing Masters Degree

                                       Level of Qualification
                                                                Level 3       Papers Towards Masters Degree

                                                                Level 2      Postgraduate Diploma

                                                                Level 1

                                                                          Programme Name - Building Towards Masters Degree

                               Please refer to for a list of approved degree programmes
I have checked that my paper/course can be used as part of a NCNZ approved qualification
Please indicate the qualification level you will obtain at completion of 2012 study (see figure in section C)
Qualification you are currently enrolled in
Will you complete this qualification in 2013?

Section D. Qualification Level: List completed papers within each qualification level that builds towards your current qu
(e.g. Postgraduate Certificate, Diploma completed)
Qualification                                                   Year          Paper Number                      Name of Paper
                                                                              / Code

Postgraduate Certificate
(Level 1)
Postgraduate Diploma
(Level 2)
Postgraduate Masters Degree
(Level 3)
Postgraduate Masters Degree (Level 4 -
Usually final two papers of degree)

Section E. 2012 Paper Enrolments
List papers you are enrolling in for 2012 (all semesters)
 Paper Code                                        Paper Name                                Paper Length Semester you Paper Point   Tertiary Education Provider &
i.e. HLTH518                                                                                 by Semester wish to Study Value           Massey- Auckland, Massey-

Thesis Dissertation:
If you are planning to undertake or are completing a research thesis, please briefly outline the topic and relevance to service.
Will you complete your current programme level in 2013?                                     If NO please indicate when you will complete the

Level Four Programme Practicum Paper
If you are planning to undertake a prescribing or non-prescribing practicum paper to complete your degree in 2012, a
support plan must be prepared before commencing the paper
Are you enrolling in a prescribing or non-prescribing practicum in 2012. If                 Draft Practicum Support plan completed? To access support
yes please contact the Nurse Consultant, Workforce & Informatics via                        to prepare a Practicum Support Plan please contact your                                                       ADON and

    A Practicum Support Plan will address the additional expectations of clinical teaching/preceptorship (often m
     mentoring and professional supervision often associated with these papers. HWNZ funding subsidises some
                  additional costs associated with completing a Nurse Practitioner prescribing practicum
Section F. Post Masters Programmes of Study/Qualifications
This section asks about 2012 enrolments towards a Post-Masters programme of study/qualification
Masters Degree Qualification Name:
Year Conferred:
Section G. Funding
Please also include details about efforts to obtain funding from other sources
Have you sought funds from other sources?
        Funding provides tuition and compulsory fees charged by the tertiary education provider (please list cost of each paper number/code if more tha

  Paper Code i.e. HLTH518                                              Paper Name                                           Estimated cost per paper
                                                                                                                          (Based on 2011 costs if 2012
                                                                                                                                fees not available)

Please indicate the number of study days your employment agreement allows. Note if your required number of study
days exceeds your entitlement you may be required to use annual leave. Please discuss with your manager.

Travel (conditions apply) - Actual costs for trainees required to travel further than 100kms Number of                      Estimated
by road one way from the usual place of work to the agreed training programme location trips:                                 costs:

Method of Travel                                                                                                           If car please
                                                                                                                          indicate Km's
Actual costs for accommodation required at the agreed training programme location. Maximum of $145 per night                Estimated
Clinical Mentoring PHC/NGO/ARC                                                              Number of                       Estimated
Clinical mentoring access costs (per hour) for clinical assessment paper required during    Hours:                          costs - no
the trainees working hours. Please complete the form by following the link below            Maximum 10                      more than
                                                                                            hours per                       $28/hour
Clinical Mentoring DHB – Hospital and Community                                             Number of                       Estimated
Clinical mentoring hours if required for clinical assessment papers - Please complete the   Hours:                          costs - no
form by following the link below                                                                                            more than
Clinical Release PHC/NGO/ARC Trainees only (conditions apply)                               Number of                      Estimated
Clinical release costs (per hour) of releasing the trainee while the trainee attends the    Hours:                         costs - no
formal aspects of their training programme, including academic and clinical mentoring                                      more than
during the trainees working hours.                                                                                         $28/hour
                                                                                                                          Total Amount
Section H. Rationale for Study & Professional Development (Career) Plan
Have you completed an annual professional development plan (PDP) as part of your annual nursing performance review
If the answer is no, please complete a PDP with your employer and include your 2012 postgraduate programme of study
required for all postgraduate funding applications
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 enhance your ability to contribute to nursing or midwifery in the C&C DHB region:

3, Fits with your career plan:

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 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 ADON/ADOM for approval who sends it to professional.development@ccdhb
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 docume
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 rel
the 2012 year
3. I understand that this funding is included in my overall entitlements to Professional Development Funding (see link below)
4. I consent to the disclosure of the personal information given on this form to recipients for purposes related to the advancement of m
and as required by protocols between C&C DHB and external agencies
5. I understand that as per the Professional Development Funding Framework for Nurses and Midwives (see link below) if I withdraw
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 fun
provide to C&C DHB and HWNZ the following information:
  Full name, relevant course completion information such as: date of course completion, outcome of course, pass or failure to attain a
withdrawal from course, date and reason for withdrawal

Section K.
This form and must be sent electronically to
supporting documentation must be scanned and emailed or posted to the DONM Office
Director of Nursing & Midwifery Funding & Data Administrator,
Capital & Coast District Health Board
Level 10, Grace Neill Building, Wellington Hospital,
Private Bag 7902, Wellington South 6021
             1   Paper outlines, descriptors and points download from Tertiary Education providers website:
             2   Copy of your Professional Development Plan (PDP):
             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):
In submitting this form electronically I agree to the declarations in section J:
                                                                               Thank you
 ew Zealand
  New Zealand (HWNZ)
Nursing Training
nk below).

2, 3 (summer school)
 in 2012

  at the discretion of
 applications will be
 lection and those that

 required of the
 ovider as soon as

 f of residency is required
ri and Pacific trainees. Please
t Providers

 or be able to be credited
ary Education Provider for a

e completing Tables D and E



owards your current qualification

              Paper credit   Grade

Tertiary Education Provider & Location e.g.
  Massey- Auckland, Massey- Wellington

will complete the

our degree in 2012, a practicum

mpleted? To access support
 Plan please contact your

 eceptorship (often medical),
ding subsidises some of the
ing practicum


per number/code if more than one).

 Estimated cost per paper Number of
Based on 2011 costs if 2012 study days
     fees not available)    required per

               $                           -

te programme of study - this is
will take to minimise these:

priate supporting
nd forward to the

nd the supporting documentation is

o assist with my study related costs in

 (see link below)
d to the advancement of my studies

 ink below) if I withdraw or fail a

 study relating to this funding to

pass or failure to attain a pass,


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