ESR NCBID Epidemiological Skills Development Programme

APPLICATION FORM

A separate application will be required for each course

Tick / Course title / Course dates,
start day 1/end last day / ESR funded travel / accom. / Applications close
/ 1.3 Outbreak Investigation Refresher (Gisborne) / 10 October 2016 10:00 – 13:00 / No / 19 September 2016
/ 1.2 Effective Case Investigation (Rotorua) / 26-27 October 2016
10:00 – 15:30 / No / 28 September 2016
/ 2.3 Laboratory Investigation (Wellington) / 24-25 May 2017 09:45 – 15:10 / Yes / 12 April 2017

Further course information is available here http://www.esr.cri.nz/health-science/our-services/training/

All courses are free of charge. Some courses include travel and accommodation however places are limited. All course materials and tools will be provided, unless stated.

(circle one) Mr, Ms, Mrs, Miss, Other [ ] Sex: ¢ Male / ¢ Female

Name: / Sponsoring organisation:
Position: / Do you have their support? / ¢ Yes ¢ No
Postal address:
Phone: / Mobile:
Email: / Dietary requirements:
Additional supporting
information:


PHU travel and accommodation sponsorship

Travel and accommodation is provided for public health unit staff for applicable courses only

Please note:

·  Travel funding from ESR will be limited to the cost of flights as at the ‘application close’ date. Applications received after this date will be subsidised to the value of the flights on this day and the respective Public Health Unit accepts to fund any additional costs i.e. the difference between the most cost effective option as at the deadline and the cost of flights as at the date of application. Accommodation and meals will still be fully funded.

·  Once booked, any changes to travel or accommodation will be at your own expense. ESR will book the most cost effective travel/accommodation options. Accommodation prior to or after the course will only be considered if flights on the day are not available. Once tickets have been booked, PHUs will be liable for flight cancellation costs (at ESR’s discretion). ESR will not guarantee that travel bookings will be the same as the stated preference unless you have clearly indicated that you are paying any additional costs.

Do not complete this section if travel and accommodation is not funded by ESR, see table on previous page for details

Flights required? / ¢ Yes ¢ No
departure airport / arrival airport / Preferred travel dates/time
To course
departure airport / arrival airport / Preferred travel dates/time
From course
Do you require airport transfers to/from venue? / ¢ Yes ¢ No
Accommodation required? / ¢ Yes ¢ No
All nights
Other (specify)
¢ Male ¢ Female

Participants may be required to share a two bedroom unit with another participant. Breakfasts will be provided for each night’s stay and dinners will be arranged for course nights (those arriving prior to the course will be required to self-cater for that night)

Please complete and return this application to Debbie Smith

Postal: P O Box 1475, Christchurch 8140, New Zealand

Email:

Phone +64 3 3786 780

Fax +64 3 379 6484