Get documents about "Postgraduate Mental Health Nurse Scholarships - Application form
Document Sample
Postgraduate mental health nurse
scholarships
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
answer)
If yes, record the semester and year you received the previous
scholarship.
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)
Education
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
Page 2 Department of Health
Professional development activities
Please outline relevant professional development activities.
Professional development activity Year Comments
Page 3 Department of Health
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).
Page 4 Department of Health
Course details
Course name
Tertiary institution
Address of tertiary
institution
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:
Page 5 Department of Health
Declaration
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
signature.
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 nursepolicy@dhs.vic.gov.au
You may choose to give some or none of the information requested, however we maybe unable to process your
application.
You can view the Department of Health’s Privacy Policy at (http://www.health.vic.gov.au/privstat.htm).
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
Page 6 Department of Health
Submission of applications
Application can be posted or scanned and emailed
Post: Email:
Postgraduate Nursing Scholarships MHNurseScholarships@health.vic.gov.au
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
MELBOURNE VIC 3001
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
OR
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
Page 7 Department of Health
