HWNZ funding application form

Post Graduate Education Funding (HWNZ Funding)Application Form for Registered Nurses employed with the Counties Manukau Health funding area

Name: ______

Last day for applications is:

CMDHB employees –see back page 18th September 2015.

Non- CMDHB staff- see back page by 18th September 2015.

The outcome of the application will be made known to you, in writing to your work address (unless otherwise notified),No later than 30 November 2015.

All applicants must have completed a career plan with their line manager before applying for HWNZ funding. Please see either Southnet Career Development site

Or

PLEASE NOTE: YOU WILL NEED TO APPLY FOR FUNDING EVERY SEMESTER. IF YOUR APPLICATION IS SUCCESSFUL IT IS ONLY FOR ONE SEMESTER AT A TIME.

All sections must be completed.All incomplete applications will be returned for completion

Criteria:

  • Be a registered nurse and hold a current new Zealand Nursing Council’s Annual Practising Certificate
  • Be employed in a permanent (part or full time) nursing position in a health service that is funded by Counties Manukau Health or the Ministry of Health from Vote Health monies
  • Be a New Zealand Resident or Citizen
  • Be compliant with the organisations Professional Development and Recognition Programme (PDRP) [if has one]
  • If commencing postgraduate diploma or Masters then must be proficient , expert or senior level on the PDRP
  • Career plan completed
  • Priority given to high workforce development needs as identified by MOH and CM Health strategic and workforce development documents
  • Preference given to applicants completing their qualification
  • Papers must be level 8 and be able to be credited towards a Masters of Nursing programme approved by the New Zealand Nursing Council
  • Form completed in full and within time frames including signatures by applicant and line manager

Please note: To ensure all applications are given an equal opportunity to secure HWNZ funding to undertake post graduate education,ALL the following information must be supplied. This is a requirement by Health Workforce New Zealand (HWNZ), Ministry of Healthand will only be released to HWNZ for reporting and auditing purposes and to meet the requirements of the Privacy Act 1993.

NOTE: If planning to undertake a prescribing practicum in semester 1 or 2 then the Post Registration/PDRP Lead must be notified in the end of year Funding round and section 8 must be completed.

1. Personal Details
Note: both line managers will need to support application
Note: need postal addresses to send any letters out- usually sent to work address unless indicated
Note:Email will be the main form of contact. Please print clearly. / Surname: First Name:
Date of Birth: Male Female
Work position:
Work Area (Name of Ward, Unit, Medical Centre etc):
If a Primary Healthcare Organisation please circle one:
Alliance Health Plus East Health Trust Total Healthcare
National Hauora Coalition Procare Networks Ltd
Do you work in more than 1 area: Yes No
If yes: second work area:
Work PostalAddress:
HomePostal Address:
Phone- work : Home:
Cell phone:
Email:
Years employed at organisation:
Full time equivalent (FTE) status: (hours worked per fortnight):
2. NZ Nursing Council
Note: Must be a Registered Nurse
Please ensure name is as per NCNZ website
Please send non-verified copy of APC if first time applicant / Is the name that appears on your Nursing Council of New Zealand’s Annual Practicing Certificate the same as above Yes No
If No: Name on APC:
Reason for difference:
Annual Practising Certificate Number:
Scope: Expiry Date:
Are there any “Restrictions to Practice” on your APC: Yes No
If yes-what is it?
3. New Zealand Residency Status
Note:If not a NZ citizen or resident-sorry unable to fund / NZ Born Yes No
If No, please complete below :
NZ resident/citizen Yes No
______If YES: MUSTinclude non-verified copy of certificateof citizenship/residency visa(first time applications only)
4. Ethnicity: / Please circle one:
NZ European /Pakeha European Southeast Asian Asian nfd Indian Middle Eastern Latin American/Hispanic African or cultural group of African Origin Other Ethnicity …………… Pacific Islander (please specify): …………………
NZ Maori Iwi …………………………….. Hapu………………………
Note: Maaori and Pacific funding is available to provide you with mentoring and cultural supervision. It can also be used for cultural development resources (up to a maximum of $200). A formal mentoring plan must be completed as part of this. Please contact The Nurse Coordinator PGE for further details.
If Maaori or Pacific- would you like additional funding for mentoring and/or cultural supervision(see note)? YES NO
5. Professional Development and Recognition Programme / NB. If your organisation has a portfolio process, then you MUST be compliant to receive HWNZ funding. It Will be checked.
Full Portfolio due date:
PDRP Level: please see note then circle one
Competent Proficient Expert Senior
Note: must be proficient or higher to commence a Post Graduate Diploma (if organisation has PDRP)
6. Educational Record / Year last enrolled in Tertiary education:
Current highest qualification level:
Have you received any educational funding before: Yes No
Is yes, from where?
HWNZ Yes No Year: ______
NETP Yes No Year: ______
PG Paper completed Semester 1 or 2
Director of Nursing (Accrued) Funds Yes No Year: ______
Te Pou Yes No Year: ______
Other: please specify: Year: ______
7. Education Planned
Note: if undertaking PGDiploma must be Proficientlevel or higher.
If commencing Masters- discussion must be held with CND/Nurse Leader, & CNM/CMM/TL & NE and/or Post Registration/PDRP Lead / What programme enrolled in or planned (must circle one):
BN Honours Post Graduate Certificate Post Graduate Diploma Masters
University/ Technical Institute: ______
Student ID (if Known) ______
Date (Month/year) started qualification ______
Date (Month/year) expected to complete qualification______
Is this your first paper of your qualification? Yes No
At what campus will you be studying at? ______
Do you need Travel and accommodation subsidy? Travel and Accommodation is only available if you need to travel more than 100kms from place of work one way (excluding Wintec in Hamilton for CMHealth staff)
Semester 1 Yes No
Semester 2 Yes No
Papers completedand planned to complete qualification:please clearly identify S2, 14 paper.
NOTE: if planning to undertake a nurse prescribing practicum-you MUST contact the Post Registration/PDRP Lead before completing this application form- all applications for prescribing practicum must be completed in the August application round for the both semesters- see section 8.
Semester, year / Paper number / Paper Name / Single or double semester / Points
Note: all applicants must complete a career plan as part of the performance review/appraisal process. Note:This section developed after discussion with Nurse Educator /Charge Nurse Manager (only if no Nurse Educator available) / Clinical Nurse Director / Post Registration/ PDRP Lead.
I agree that the academic plan is appropriate for the applicant to assist them meet their career goals as per their career plan, service and organisational needs. I have considered any pre-requisites and requirements for the paper.
Name:
Signature: Date:
8. ONLY to be completed if undertaking a prescribing practicum in 2016.
Must be discussed with your CND/ Nurse Leader
Note: it is the expectation of CM Health that if the supervisor is an employee of CM Health then the supervision will be undertaken within work time and therefore require no additional funding / ONLY to be completed if undertaking a prescribing practicum in 2015
Please outline your proposed arrangements for the Prescribing Practicum ONLY:
Clinical Access hours required :
Clinical Supervisor:
Costings of supervision:
Any other costs:
9. Rostering requirements / Number of days education leave required:
Note. 15 points paper: 3-4 study days. 30 point paper: 6-8 study days. (Applicable for online papers also, note if the education days fall on your normal rostered day off, then you might not get paid education leave).
10. Line Manager Agreement
Note: all applicants must have completed a career plan as part of their performance development review.
Note: if work in 2 areas, both line managers must support the application. / I have reviewed and discussed the above with the applicant.
  • In signing this form I fully support and endorse this application for funding.
  • I have also considered the rostering implications and the needs of the clinical area and I am aware and will support the number of study days involved.
  • I have seen and discussed the career plan of the applicant as part of the performance review/ appraisal process
  • I have discussed with the applicant how he/she will apply new knowledge and skills back into the clinical area
Name: Position:
Signature: Date:
11. Applicant Agreement / By signing this application I agree that:
  • I have completed a career plan as part of my performance review process
  • I will enrol into the university within the university timeframes.
  • I will contact the Nurse Coordinator - PGE of any changes in my enrolment in writing.
  • Failure to successfully complete the Post Graduate Qualification I have indicated (for reasons other than those beyond fair and reasonable causes) may result in CM Health retrieving the monies back (see Policy)
  • CM Health can seek confirmation of course completion and result from the university/technical institute involved
  • CM Health can release my details to HWNZ as per the Privacy Information Act (1993)
  • My name may be provided to other students so they can contact me to discuss the papers I have completed or are currently undertaking.
  • I understand that if I do not meet the criteria stated above, I may not receive any funding
  • I agree that if I am unsuccessful in my application, then my name can be placed on a wait list.
Name: Date:
Signature:
For further information contact:
Dianne Barnhill
Post Registration/PDRP Lead
Phone: 09-2760044 ext 8691
Fax: 09-2595077 (internal: 5077)
Mobile: 021 221 4816 (internal *3569)
Room 312, level 3, Support Building
MiddlemoreHospital
Private Bag 93311
Otahuhu.1640
Email: / If CM Health staff- send application form to your Line Manager (CNM, TL etc) or if a senior nurse to your CND.
If Primary Health Care Nurses send to:
Karyn Sangster Nurse Leader Primary Health care
Building 3/19 Lambie Drive,
Private Bag 94052, South Auckland Mail centre, Manukau 2240.
All Others send to:
Contracts & Placements Officer , NPDU, 3rd Floor, Support Building
MiddlemoreHospital
Private Bag 93311,Otahuhu, Auckland 1640

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Developed by Nurse Coordinator, Post Graduate Education. March 2007, updated 2015.