Postgraduate Mental Health Nurse Scholarships - Application form by Zf2cT6j


									Postgraduate mental health nurse
Semester 1 2011

Application form
Closing date:
Prior to completing this application, please refer to the Semester 1 2011 Guidelines for Applicants.
Please complete all fields in this application form and ensure you sign the declaration. Only signed application
forms that have been endorsed by a Senior Psychiatric Nurse will be accepted. To submit your completed
application, the signed form can be scanned and emailed or posted (details below).

Applicant information
Title                                      Surname

Given name

Residential address

Suburb                                     State                               Postcode
Postal address
(if different to above)

Suburb                                     State                                 Postcode

Work phone                                 Home phone                            Mobile phone

Email address

Are you an Australian citizen, permanent resident or New Zealand citizen? (circle answer)         Yes       No

Are you of Aboriginal or Torres Strait Island origin? (circle answer)                             Yes       No

Registration information
Nursing and Midwifery                                       Registration expiry date
Board of Australia
registration number

Registration category                                       Current endorsement as          Yes           No
(general or specific)                                       a midwife? (circle answer)
Have you received a Postgraduate Mental Health Nurse Scholarship from the                   Yes           No
Department of Health (previously the Department of Human Services)? (circle

If yes, record the semester and year you received the previous
Please record the course title and institution of the course of
study for which you received the previous scholarship

                                                                                            Department of Health
Employment during course of study
Is your employer aware that you are undertaking a course with a supervised clinical               Yes         No
component? (circle answer)
If not, provide explanation:

Does your employer support you to undertake postgraduate studies if paid leave is                 Yes         No
required? (circle answer)

Do you intend to continue working in mental health in a Victorian public health service for       Yes         No
at least 12 months full-time or pro-rata equivalent following completion of your course of
study? (circle answer)

Provide details of relevant post secondary educational background including qualifications
Year of course    Name of course / program of      Institution / education           Additional comments
completion        study                            provider

Professional experience
Provide details of relevant professional experience, including the role you will be in during your course of study.

Dates             Position                Clinical / professional experience           Additional comments

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Professional development activities
Please outline relevant professional development activities.

Professional development activity                  Year        Comments

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Commitment to mental health nursing
Provide a statement outlining your commitment to mental health nursing.

Include information about research activities, self-directed learning, professional development or a statement
about how your course of study will assist your intended career path.
What are your career aspirations in mental health?
How will the scholarship contribute to your ability to undertake the course? (Information may be included about
your personal situation).

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Course details
Course name

Tertiary institution

Address of tertiary

Suburb                                     State                                 Postcode

Are you enrolled in this course for Semester 1, 2011? (circle answer)                                Yes           No

Commencement date                                           Completion date
                                     /           /                                               /             /
(dd/mm/yy)                                                  (dd/mm/yy)

What qualification level will you attain? (circle answer)   Graduate certificate            Graduate diploma
                                                                   Masters                           PhD

Are you studying full time or part time? (circle answer)          Full time                     Part time

Course place (circle answer)                                   Full fee paying        Commonwealth supported
                                                                                        place (HECS-HELP

Fee payment method (circle answer)                           Upfront payment to              FEE-HELP loan
                                                              tertiary institution

                                                                HECS-HELP                      Combination

Funding support

Have you received funding from another source to support you in undertaking this                     Yes           No
course? E.g. employer, professional body etc (circle answer) Exclude loans from your
employer or other bodies that you are required to repay in full.

Name of source

Amount                           $

Other information
How did you find out about this scholarship?                    Employer                      Course provider
(circle answer)
                                                                Colleague                        Advertising
                                                        Nursing in Victoria website         Other, please specify:

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In signing this Application Form, I declare that to the best of my knowledge, the information I have provided is
true and correct. I declare that I have read the Guidelines for Applicants and agree to the scholarship
conditions if my application is successful. I understand that scholarships are allocated at the discretion of the
Department of Health and that the decision of the department is final. Applications will not be accepted without a
Applicant Name:                       Signature:                             Date:
                                                                                       /             / 2011

Privacy Statement
The Department of Health is collecting your personal information to allocate scholarships and for the
development of policy relating to the nursing workforce. Your information may be disclosed to named employers
and universities in order to assist us in assessing your eligibility, for data collection and for administration
purposes. You can access your personal information held by the department by contacting the Nurse Policy
Branch on 03 9096 7528 or by email on
You may choose to give some or none of the information requested, however we maybe unable to process your
You can view the Department of Health’s Privacy Policy at (

Endorsement of Senior Psychiatric Nurse
The endorsement of the Senior Psychiatric Nurse is required for this application to be considered.
Name:                                                     Area Mental Health Service:

I declare that as Senior Psychiatric Nurse at a Victorian public health service:

        I am aware of and support the applicant’s course of study in mental health nursing /
         advanced mental health practice

        I have verified that this application form is complete

        I can substantiate that the applicant is employed (or commencing employment) within
         mental health in the Victorian public health service listed above.

Signature:                                                Date:
                                                                         /           / 2011

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Submission of applications
Application can be posted or scanned and emailed

Post:                                              Email:
Postgraduate Nursing Scholarships        
Semester 1, 2011                                   Note: if emailing completed application form,
Office of the Senior Nurse Adviser                 please print the form and sign the declaration
Mental Health, Drugs and Regions Division          before scanning and emailing the signed
Department of Health                               copy to the above email address
GPO Box 4541

Supporting Documentation
For this application to be considered, applicants are required to submit a number of
supporting documents at the time of application. These must include:
  Evidence of Australian citizenship or permanent residency or New Zealand citizenship
  (Applicants from New Zealand must submit a copy of their current passport)
  Copy of current Nursing and Midwifery Board of Australia registration – front and back –
  showing name, registration number, endorsements and if there are conditions or
  restrictions on registration
  Evidence of enrolment in Semester 1 2011, which may be in the form of:
          An official university letter confirming enrolment
            An official Student Tax Invoice or Statement of Account for Semester 1 2011.
  Information provided must include:
          The names of enrolled units, subjects or courses for Semester 1 2011
          The enrolment status – part time / full time course load
            The type of place / student status – e.g. Commonwealth Supported Places (CSP),
             Higher Education Loan Program (HECS-HELP) or Full-fee paying (FFP-HELP)

             The closing date for applications is 25 February 2011
                    Late applications will not be accepted
             Applications must include supporting documentation

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