Docstoc

Bursary_Application

Document Sample
Bursary_Application Powered By Docstoc
					 WA Country Health Service


      Travel and Accommodation
               Bursary
       For Nurses and Midwives




Application Form 2010 - 2013


Funded by:

Nursing and Midwifery Office, Department of Health
                       APPLICATION FORM
                       Travel and Accommodation Bursary
                            For nurses and midwives
                                                                Applicant Number 001

PERSONAL EMPLOYMENT DETAILS
Surname: _______________________________________________________
First and Second Names: ___________________________________________
Residential Address: ______________________________________________________
Suburb/Town: ___________________ State: ____________Post Code: ____________
Postal Address:                                ____________________________________
Contact Number (home): ______________________________
Mobile Number: _____________________________________
Email Address: _______________________________________________________
Current Employer: ____________________________________________________
Name of Health site: ___________________________________________________
Current Position Held: _________________________________________________

WA Health Employee Payroll number (as per pay slip):             ___________________


Employed by: WACHS              SMAHS           NMAHS
                 CAAHS          WNHS            NOT YET EMPLOYED
                 Other (please specify): ________________________

Australian Health Practitioner Regulation Agency Registration (or Nurses and
Midwives Board of Australia) number (if applicable): _________________________


Qualification:    EN           RN               Midwife          Nurse Practitioner
                 Other (please specify): ________________________

Are you of Aboriginal or Torres Strait Islander descent?        Yes
Are you an Australian Citizen?                Yes               No
OR a permanent resident of Australia?         Yes               No
* Non WA Health employees must provide certified copies of proof of citizenship or residency




                                                                              Page 1 of 9
ACCOUNT DETAILS FOR PAYMENT

I agree I have booked and paid for my travel and accommodation. Yes                  No

If Yes, please complete personal bank details at Section A.

If No, please complete Section B. where your Health Service made travel and
accommodation bookings on your behalf.

The Bursary will not part pay an individual applicant and the Health Service for a
single application.


SECTION A. BANK TRANSFER – TO INDIVIDUAL APPLICANT

Name of Bank: ____________________________________

BSB number:
Account number: __________________________________
Name of Account Holder: ____________________________             (please print clearly)



SECTION B.          JOURNAL TRANSFER - TO HEALTH SERVICE


Name of health service: ________________________________
Cost centre: ______________________
Name of account holder: __________________________________
Name of cost centre manager: _____________________________



COURSE DETAILS

1. Name of Course: ________________________________________________

2. Education institution/ or course provider: ______________________________

3. Would you have undertaken the course without this travel and accommodation
   bursary?
                                           Yes            No




                                                                     Page 2 of 9
COURSE DETAILS - continued


4. Please complete the following Table:


Program name or         Venue/location of        Study                    Total number of days away
Unit Title              theory and/or clinical   commencement and         including travelling duration
                        practicum                end date
                                                                   th
E.G. Advanced           Theory (T): TAFE,        T: Mon 10 to Fri 14      Total days away = 17
Diploma in EN –         Clinical Placement       January 2011             i.e. 3 week course (Mon - Fri)
                                                                     th
Clinical Practice 321   (CP): SCGH               CP: Mon 17 to Fri 28     plus 2 travel days (arrival prior
                                                 Jan 2011                 and departure post course)




FUNDING
Have you applied for or received funding from any other source for travel and
accommodation to undertake this course?
                                                  Yes            No



If yes, please give details of the source, and the amounts requested or received:


Other Source: __________________________Year:__________ $: _____________
Other Source: _________________________ Year: __________ $: _____________

Note: If successful with this application, you are not eligible to apply for funding from
any other source for travel or accommodation.




                                                                                 Page 3 of 9
STATEMENT OF INTENT


I declare that the information supplied by me for this application is true and accurate.


I acknowledge that any statement, found to be false or deliberately misleading, will
void this application.


Applicants Signature: _________________________ Date: ___________________


Witness Name: ______________________________


Witness Signature: ___________________________ Date: ___________________




Note: For WACHS applicants your regional Nurse Director will be informed of your
application.




                                                                      Page 4 of 9
CHECKLIST TO COMPLETE YOUR APPLICATION
Please post or email completed application (pages 1-5 inclusive) with all supporting
documentation to;

Marked:          Bursary Application Att: Pamela Coates
                 WA Country Health Service
                 PO Box 6680 East Perth Business Centre
                 Western Australia 6892                                  OR

Email:           WACHStravelbursary@health.wa.gov.au

If you are not a current WA health employee all required documentation must be
certified as a true copy of the original (Appendix 1). DO NOT send originals.

Current WA Health employees must provide photo copies. DO NOT send originals.

1. NON WA HEALTH EMPLOYEES
     Completed Application Form - pages 1. to 5. with signature on page 5.
     Certified proof of Australian citizenship or permanent residency. Include one;
         o Australian birth certificate
         o Australian passport
         o Australian citizenship, or
         o Australian permanent visa
     Certified proof of current Australian Health Practitioner Regulation Agency
      registration (AHPRA) (if applicable).
     Certified proof of course theory/ practicum completion AND duration of course.
     Sign and date Application Form on Checklist page 5.


2. CURRENT WA HEALTH EMPLOYEES
    Completed application form - pages 1. to 5. with signature on page 5.
    Copy of proof of current Australian Health Practitioner Regulation Agency
     registration (AHPRA).
    Copy of course theory and/or practicum completion AND duration of course.
    Sign and date Application Form on Checklist page 5.


SIGN: _________________________________                          DATE: ____________________

PRINT NAME: _________________________________




Applicants advised to seek financial advice for tax implications if in receipt of Bursary. www.ato.gov.au




                                                                                     Page 5 of 9
COMPLETING THIS FORM
The Bursary is designed to provide financial assistance for travel and
accommodation for eligible nurses and midwives undertaking theoretical/ clinical
practicum >100kms from their usual place of residence.


WHO MAY APPLY
  1. Currently employed WA public health nurses and midwives. Part-time, full-
     time, permanent or contracted staff, and

   2. Nurses and midwives undertaking a refresher course to gain employment in
      the public health system as a nurse or midwife.


ELIGIBLE COURSES
    Nursing and midwifery post graduate education (e.g. post graduate diploma in
      nursing or midwifery) or post registration studies (e.g. EN advanced diploma)
      that leads to a higher qualification and require theoretical or clinical practicum
      at a rural or metropolitan site.

       AND

      These studies are based in Western Australia at an;
          o Education institution i.e. Vocational Education Training (VET) or
             higher/tertiary education;
                  OR
          o Education provider funded by the Nursing and Midwifery Office, DOH


Bursary link: http://www.nursing.health.wa.gov.au/scholarship/travel.cfm


ELIGIBILITY CRITERIA
    Applicants must hold an Australian citizenship or permanent residency and
      reside in WA with a;
          o Australian birth certificate,
          o Australian passport,
          o Australian citizenship, Or
          o Australian permanent visa

      Applicants must provide proof of current registration with Australian Health
       Practitioner Regulation Agency (AHPRA).
      Course or study unit is for a minimum of 2 days and no greater than 4 weeks.
      Applicants must have successfully completed the course or study unit i.e.
       bursary funding is paid retrospectively - after course/unit completion.
      Applicants attending a metro based course must reside in a WACHS region.




                                                                      Page 6 of 9
NOT ELIGIBLE
   Bursary funding is not available for professional development study days,
     international or national seminars, workshops or conferences.
   Applicant’s who have received payment for travel and accommodation from
     any other source.
   Those applicants employed on a casual basis.


CONDITIONS OF FUNDING
   Bursary funding awarded to assist with travel and accommodation only.
   Payment is made retrospectively at completion of course or study unit.
   One bursary application permitted per year, more often subject to funding.
   Study and/or placement must be undertaken in WA only.
   Applicants primary residence must be > 100km from the education provider or
    clinical placement site;
        o Wheatbelt placement e.g. Northam and York are eligible for funding.
        o Placements in Mandurah are not eligible for funding.
   Study and placement is for a minimum of 2 days and no greater than 4 weeks.
   Bursary funding may include up to 2 additional days beyond course or study
    days to assist with long distance travel. Weekends stays are not included.


NOTES
   Sum awarded is not intended to cover full cost of travel and accommodation.
   Bursary funds may be considered assessable income for personal taxation
    purposes. Applicants are responsible for any related tax liability.
   Payment will be processed within 6 weeks of receipt of completed application.


FOR FURTHER INFORMATION

Contact:    Pamela Coates
            WA Country Health Service (WACHS)
Tel:        (08) 9223 8551

Email:      WACHStravelbursary@health.wa.gov.au

Website:    http://www.nursing.health.wa.gov.au/scholarship/travel.cfm




                                                                 Page 7 of 9
                                                                      APPENDIX 1
DOCUMENTATION CERTIFICATION
The following wording is to be used to certify documents:

    ‘I certify that this is a true copy of the original which I have sited today’

The signature block must contain the (i) signature, (ii) name (printed), (iii) title of
office and (iv) date signed by the certifying officer.

The following officers are authorised to certify documents:

      A Commissioner of Declarations
      Justice of the Peace
      A registered nurse/midwife
      The chief executive officer or deputy chief executive officer of a local
       government
      A member of the council of a local government
      An Electoral Registrar appointed under the Electoral Act 1907
      A person appointed to take charge of a post office in the state
      An officer of the State or Commonwealth public service
      A teacher within the meaning of the Education Act 1928
      A police officer
      A person appointed to take charge of the head or any branch office of a society
       within the meaning of the Building Societies Act 1976 or a credit union within the
       meaning of the Credit Unions Act 1979
      A secretary of an organisation of employees or employers registered under the
       Industrial Relations Act of 1978 or of a organization registered under the
       Conciliation and Arbitration Act 1904 of the Commonwealth
      A practitioner within the meaning of the Legal Practitioners Act 1893
      A medical practitioner registered under the Medical Act 1894
      A pharmaceutical chemist within the meaning of the Pharmacy Act 1964
      A member of the academic staff of an institution providing courses at post-
       secondary education level
      The holder of a licence under the Real Estate and Business Agents Act 1978 or
       the Settlement Agents Act 1981
      An insurance broker registered under the Insurance (Agents and Brokers) Act
       1984 of the Commonwealth
      A person who is accredited as a chartered accountant or a certified practising
       accountant
      A surveyor licensed under the Licenses Surveyors Act 1909
      A patent attorney registered under the Patents Act 1990 of the Commonwealth


PLEASE NOTE: A close family member e.g. direct family member or one
related by marriage is not eligible to certify your documents.




                                                                      Page 8 of 9
                                                                       APPENDIX 2

BURSARY FUNDING

Bursary funding is available for an eligible course or unit of study for the duration of 2
days minimum and no greater than 4 weeks.




Maximum bursary funding allocation

                                                          Accommodation
                             Travel funding               funding per day -
Travel distance - one        allocation – for return      during course - does
way                          journey i.e. 2 ways          not include weekends

100-250km                               $200                         $150
251-450km                               $300                         $150
451-750km                               $500                         $150
751-1000km                              $600                         $150
1001km+                                $1100                         $150




GLOSSARY OF TERMS

AHPRA                              Australian Health Professional Regulatory Agency
DOH                                Department of Health
NMBA                               Nurses and Midwives Board of Australia
NMO                                Nursing and Midwifery Office
Non WA Health employee             Applicant not currently employed by an area health
                                   services, hospital or Department of Health
WACHS                              WA Country Health Service




                                                                       Page 9 of 9

				
DOCUMENT INFO
Shared By:
Categories:
Tags:
Stats:
views:34
posted:9/20/2011
language:English
pages:10