All Information on This Form Is Compulsory and Must Be Completed

CMART application form 2016

All information on this form is compulsory and must be completed.

Please submit all academic certificates, a copy of your ID document and proof of SANC registration with your application.

Title
Name
Surname
Preferred name and surname (for certificate)
Ethnicity
Nationality
Home language
Disability / ð  Yes
ð  No
Wheelchair / ð  Yes
ð  No
Date of birth
ID number
SANC number
SU student number (if you have studied with SU before)
Postal address
Courier address
Name and address of employer
Name of facility and address where you are working
Home telephone number
Work telephone number
Cellphone number
Email address
Name and contact number of supervisor / facility manager at work
Name and contact number of NIMART supervising mentor for the facility / sub-district where you are currently working who have agreed to mentor you
Payment responsibility / ð  Employer
ð  Private
Formal academic training
Name of degree/diploma/certificate / Academic institution / Diploma/ Degree/ Certificate / YEAR
Short courses / YES / NO / YEAR
PACK HAST module compulsory for CMART
IMCI compulsory for CMART
At the clinic where you are currently working:
*If ‘no’ to any of the below, you need to organize with your supervisor at work to get the necessary exposure in order to complete the course requirements / YES / NO
Adults with HIV receive routine HIV care
Children with HIV receive routine HIV care
Pregnant women with HIV receive routine HIV care
Adults are initiated on ART
Children are initiated on ART
Pregnant women are initiated on ART
Adults on ART receive follow-up care
Children on ART receive follow-up care
Pregnant women on ART receive follow-up care
TB screening for adults, children and pregnant women are available
Adults, children and pregnant women receive TB treatment
Did your supervisor approve your study leave? Please attach proof.
Is the NIMART supervising mentor for your facility / sub-district aware that you are attending the course? Please attach proof.
Have you completed the provincial NIMART programme?*

*Western Cape: Nurses that have completed the provincial NIMART programme do not need to apply for CMART

Please take note of the following dates:

Workshop dates / Exam dates
09 May – 20 May 2016 / 27 – 28 September 2016

It is compulsory to attend all the workshop and exam days.

Application closing date: 29 April 2016

Applications can be emailed to