2015 Application Form

2015 APPLICATION FORM

Health Professional Level 3

Personal Upgrade Scheme

for the Recognition of Excellence

2015 APPLICATION PACKAGE

LIST OF CONTENTS IN THIS PACKAGE

Applicant Coversheet Pages 3-4

Application Form

o Part 1: Application Addressing Mandatory Criteria Pages 5-6

o Part 2: Application Addressing Elective Criteria Pages 7-8

Applicant Checklist & Statement Page 9

Application Submission Details Page 10

APPLICANT COVERSHEET

2015 HEALTH PROFESSIONAL LEVEL 3 PERSONAL UP-GRADE SCHEME
for the
RECOGNITION OF EXCELLENCE
ACT Health Directorate
Community Services Directorate
Education and Training Directorate
Justice and Community Safety Directorate
Calvary Health Care Bruce
APPLICANT DETAILS
Preferred title: / Family name: / Given names (in full):
Address:
(Home or work)
Phone Number: / Work: / Home: / Fax:
Email: (Home or work)
Mobile:
Are you permanently appointed as a Health Professional Level 3? Yes/No
If No-you are not eligible to apply.
Have you served a minimum of 12 months at
HP3 Pay Point 3 in the ACT Government
Yes/No
Please attach a letter from Shared Services Payroll or Calvary Payroll confirming your permanent appointment and the date at which you commenced on HP3.3 (3rd increment). You must have been at HP3.3 for a period of at least 12 months, as at closing date 30 June 2015. / IMPORTANT
If you wish to claim jursidictional equivalence (ie that a role you had immediately prior to joining ACT Health was equivalent in work level standard to HP3.3) please contact the Scheme Secretariat to discuss your situation as soon as possible and before preparing an application.
Are you currently subject to an under-performance process?
Yes/No
Job title: / Profession:
Directorate: / HP3 Position Number:
Duty Statement
Please attach the Duty Statement for your substantive HP3 position as well as an up to date job description.
If the Duty Statement does not adequately reflect the current HP3 duties of your position please attach a single A4 page listing the main functions of your substantive HP3 position, for example ‘clinical/laboratory work, teaching, project work, interpretation of legislation, service coordination, health promotion, etc”.
Please ensure that your current supervisor/manager signs off to validate this additional information.
Applicant’s signature: DATE: / / 2015
SUPERVISOR / MANAGER SIGN-OFF
Supervisor/manager must sign off and validate THE APPLICANT’S claims in this application.
NB: Supervisor/manager must be at HP4 or above level (or equivalent);
If supervisor/manager is acting in the role, then must have been acting for minimum of 6 months.
Supervisor/Manager Name:
Supervisor/Manager job title:
CONTACT DETAILS OF SUPERVISOR/MANAGER
Address:
Phone number: / Fax number: / Email:
I confirm that I have read the applicant’s application for the HP3 Personal Upgrade Scheme for the Recognition of Excellence and, having read the applicant’s response to each criterion, I confirm that I have signed against each response to verify that to the best of my knowledge the claims made by the applicant in this application reflect the work undertaken by them in their HP3 role, and are true and accurate.
YES /NO
I have signed and validated the applicant’s response to each criterion and support the applicant’s case for a personal up-grade for professional excellence.
YES /NO
Where No has been indicated, comment must be made: (This may be an attachment)
COMMENT...... ………………………………………………………………………………………………………………………………………………………………………………...……………………………………………………………………………………………………………......
Have you discussed your comments with the applicant?
YES/NO
NB: Where NO has been indicated, an applicant may still submit an application to the panel for consideration.
Supervisor/Manager’s signature:
Date: / / 2015
REFEREE DETAILS
(cannot be same person as Supervisor/Manager AND must complete the separate Referee Report Form)
Referee Name:
Job Title:
Work contact number: / Email:
Relationship of referee to applicant:

PART 1: MANDATORY ASSESSMENT CRITERIA

2015 Health Professional Level 3 Personal Upgrade Scheme
for the Recognition of Excellence
ACT Health Directorate
Community Services Directorate
Education and Training Directorate
Justice and Community Safety Directorate
Calvary Health Care Bruce
APPLICANT DETAILS
Preferred title: / Family name: / Given names(in full):
· Application must be typed.
· Where appropriate, dot points may be used.
· Evidence must be attached where relevant to validate claims.
MANDATORY CRITERION 1
Extensive specialist or generalist knowledge skills and experience within your area of work, recognised through a consultant role utilised by peers and other professionals.
(Start response here- one A4 page per criterion recommended)
Supervisor/Manager: I confirm that I have read the applicant’s response to this criterion and that to the best of my knowledge, the claims made by the applicant against this criterion are true and accurate.
Signature:
Date: / / 2015

PART 1: MANDATORY ASSESSMENT CRITERIA

2015 Health Professional Level 3 Personal Upgrade Scheme
for the Recognition of Excellence
ACT Health Directorate
Community Services Directorate
Education and Training Directorate
Justice and Community Safety Directorate
Calvary Health Care Bruce
APPLICANT DETAILS
Preferred title: / Family name: / Given names(in full):
· Application must be typed.
· Where appropriate, dot points may be used.
· Evidence must be attached where relevant to validate claims.
MANDATORY CRITERION 2
Development, implementation and evaluation of significant and relevant project(s) or service change(s) that enhance the efficiency and/or effectiveness of organisational services.
(Start response here- one A4 page per criterion recommended)
Supervisor/Manager: I confirm that I have read the applicant’s response to this criterion and that to the best of my knowledge, the claims made by the applicant against this criterion are true and accurate.
Signature:
Date: / / 2015

PART 2: ELECTIVE ASSESSMENT CRITERIA

2015 Health Professional Level 3 Personal Upgrade Scheme
for the Recognition of Excellence
ACT Health Directorate
Community Services Directorate
Education and Training Directorate
Justice and Community Safety Directorate
Calvary Health Care Bruce
APPLICANT DETAILS
Preferred title: / Family name: / Given names(in full):
Please address ONLY 2 of the 10 elective criteria options.
INSERT YOUR FIRST ELECTIVE CRITERION NUMBER (Eg EC3 )
and CRITERION DESCRIPTION HERE
· Application must be typed.
· Where appropriate, dot points may be used.
· Evidence must be attached where relevant to validate claims.
(Start here - one A4 page per criterion recommended)
Supervisor/Manager: I confirm that I have read the applicant’s response to this criterion and that to the best of my knowledge, the claims made by the applicant against this criterion are true and accurate.
Signature:
Date: / /2015

PART 2: ELECTIVE ASSESSMENT CRITERIA

2015 Health Professional Level 3 Personal Upgrade Scheme
for the Recognition of Excellence
ACT Health Directorate
Community Services Directorate
Education and Training Directorate
Justice and Community Safety Directorate
Calvary Health Care Bruce
APPLICANT DETAILS
Preferred title: / Family name: / Given names(in full):
INSERT YOUR SECOND ELECTIVE CRITERION NUMBER (Eg EC3 )
and CRITERION DESCRIPTION HERE
· Application must be typed.
· Where appropriate, dot points may be used.
· Evidence must be attached where relevant to validate claims.
(Start response here- one A4 page per criterion recommended)
Supervisor/Manager: I confirm that I have read the applicant’s response to this criterion and that to the best of my knowledge, the claims made by the applicant against this criterion are true and accurate.
Signature:
Date: / /2015

APPLICANT CHECKLIST & STATEMENT

2015 Health Professional Level 3 Personal Upgrade Scheme
for the Recognition of Excellence
ACT Health
Community Services Directorate
Education and Training Directorate
Justice and Community Safety Directorate
Calvary Health Care Bruce
APPLICANT NAME:
I confirm that I have read the Applicant Checklist BELOW and that I have completed each item on the checklist;
· I have read the Scheme Overview, Explanatory Guide to the Assessment Criteria and Document Submission Guidelines;
· I have attached and completed a 2015 Application Coversheet;
· I have not referred to or attached any confidential client information;
· I have attached a copy of my substantive HP3 position Duty Statement and/or a brief description of the primary functions of my substantive HP3 position (validated by my supervisor/manager);
· I have attached a letter from Shared Services Payroll or Calvary Payroll confirming my permanency and my minimum 12 months employment in ACT Government or Calvary Health Care Bruce at HP3.3 paypoint;
· I have attached my completed responses to the 2 Mandatory Criteria ;
· I have attached my completed responses to TWO ONLY of the 10 Elective Criteria;
· I have provided my completed application (including evidence) to my supervisor/manager to read;
· I have obtained my supervisor/manager sign-off and validation of my responses to the assessment criteria;
· I have provided my completed application (including evidence) to my referee to read;
· I have obtained & attached my referee report including my referee’s sign-off of my responses to the assessment criteria;
· I have attached relevant documentation and evidence to support my application and my assessment responses to the criteria;
· I have compiled my application as an electronic document-please note only electronic applications will be accepted in accordance with the Document Submission Guidelines.
APPLICANT STATEMENT
I confirm that the information contained within this application is :
- Based on my substantive position as an Health Professional Grade 3 (pay point 3 or jurisdictional equivalent);
- Based on experience, skills and knowledge pertaining to my substantive position as per above;
- Supported by evidence as per attachments appended to this application;
- Supported by my supervisor/manager and by the attached Referee Report;
- Based on my completion of the application checklist as per below;
- True and correct.
Signature: / Date:: / / 2015

SUBMISSION INSTRUCTIONS

Receipt of Application

Please indicate below how you would like to have receipt of your application confirmed.

□ By email-please advise preferred email address

□ By standard mail to home address

□ By standard mail to other address

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