Family Name
First Name
NPB ID Number
Health services has received VNPP model development Funding? (circle one)
/ Round 4.2 Round 4.3 Round 4.4
Round 4.5 Round 4.6 No VNPP funding
Applicant is NPC with VNPP Support package? (circle one)
/ Yes / No / To be confirmed with HS

Nurse Policy Branch

use only

2010 APPLICATION FORM

CLOSING DATE 5pm,7 December 2009

Applications should be marked CONFIDENTIAL and addressed:

 / NP Scholarships - 2010
Nurse Policy Branch
Department of Health
GPO Box 4057
MELBOURNE 3001
@ /
Subject: NP Scholarships – 2010

DoH Contact details

1300 662 685

@

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Criterion 1 & 2 – Applicant details

Title / Family Name / Given Name/s
Residential Address
Suburb / State / Postcode
Postal Address
(If different than above)
Phone / Work / Home or mobile
e-mail
Are you an Australian or New Zealand citizen or permanent resident? /  Yes  No
Are you of Aboriginal or Torres Strait Islander origin? /  Yes  No
Nurses Board of Victoria registration number /

Expiry date

Criterion 3 - Details of employment during course of study (2010)

Name of Employer
Work address
Suburb / State / Postcode
Position/Job title / Grade/
Classification
Area of practice / Location/
Campus
Employment status /

 Full time  Part time  Casual/Bank

/

FTE

Name title of employer contact person (e.g. Nurse Unit Manager or DON)
Is your employment for 2010 confirmed? /  Yes  No / If not, provide explanation:

Criterion 4 - Details of relevant education / Clinical background

Provide details of the relevant POST REGISTRATION education you have completed

Year of course completion / Name of course/program of study / Institution/education provider / Additional comments

Provide brief details of RELEVANT professional experience that demonstrates career trajectory towards NP practice level.

Dates / Description of clinical/professional experience / Additional comments

Details of RELEVANT professional experience (Contd)

Dates / Description of clinical/professional experience / Additional comments

Criterion 5 - Evidence of organisational support

Have you been appointed by your employer as Nurse Practitioner candidate? / Yes – If yes, when were you appointed
No, but currently being discussed
Have not had any discussions with my employer/DoN
Are there other Nurse Practitioner (and/or NP Candidates) in your organisation? / Yes
No
Don’t know
Through which NBV pathway will you be seeking endorsement as NP? / NBV Pathway 1
NBV Pathway 2
Don’t know
If you are using pathway 2, have you had an equivalency assessment or advice from NBV about the preparation you need to undertake? / Yes
 No

Criterion 5.1 – Non VNPP funded

Applicants in health services that are NOT being supported as a NPC with VNPP funding (Rounds 4.2-4.6 inclusive) are required to provide the following details and obtain Director of Nursing (or equivalent) sign off of this section:

Is this applicant’s area of practice a key part of your organisation’s current strategic direction or service plan? / Yes, strongly aligned  Neutral
 Some alignment  Don’t know
*Legend tick as appropriate
A = Agreed C = Commenced/under consideration N = Not yet formulated N/A = Not applicable / A* / C* / N* / N/A*
Will there be a NP position available for the applicant in your organization after endorsed by the Nurses’ Board of Victoria?
Will the organisation facilitate the applicant’s use of current EBA entitlements to ensure timely completion of this course? (Professional development leave, study leave, exam leave postgraduate study leave)?
Are there existing processes for implementation of NP roles in your organisation? (e.g. position descriptions for NP & Candidates, NP steering committee or Practice C’tee)?
Are there processes resources identified to support the change management activities to implement a sustainable model of care incorporating this applicant? (eg redesign care processes, clinical/corporate governance structures, stakeholder engagement)
Are there processes to provide clinical and professional mentorship/supervision for this applicant?(This who may provide mentoring, additional time allocated for supervised clinical practice, internship programs, backfill arrangements for Nurse Practitioner Candidate and / or clinical mentor)
Is there understanding and commitment to this advanced and extended nursing role and service development from key clinical stakeholders in the area of practice/clinical service? (This includes support from relevantheads of Nursing, Medicine, Pharmacy, Radiology, Pathology)
Will the organsiation provide other in-kind contribution/organisational supports to this applicant to facilitate their course completion and preparation as a NP?(Eg: additional non-clinical time, education resources, facilitation of travel)

Criterion 6– Course details for 2010

Name of course
Name of tertiary institution / State
Commencement date of course / / / 20__ / Anticipated completion date: / / /20__
What qualification will you attain with this funding? / Masters Degree
Master level units/modules, specify______
Course fees for 2010(Estimate your fees semester 2 exclude amenities fees) / Semester 1 2010 / $ / Semester 2 2010 / $
Study load in 2010 /  Part time studies  Full time studies
Course Place /  Full Fee Paying  Commonwealth Supported Place (CSP or HECS)
Fees payment method for 2010 /  Upfront payment to university  FEE-HELP Loan
 HECS-HELP  Combination
NOTE: Successful applicants are required to pay course fees or student contribution/HECS direct to university by the due date or defer payment by taking out a FEE-HELP or HECS-HELP loan. Full fee paying students must provide a University Tax Invoice with details of payment/loan amounts. Successful applicants are required to provide evidence of enrolment.
Successful applicants are required to provide evidence of enrollment when accepting the scholarship.

Criterion 7- Other sources of funding sought for this study

Have you been awarded a scholarship, grant or professional development funds from another source for this course? E.g. Employer, Professional body etc.Exclude loans from your employer/ other bodies that you are required to repay. / Yes
No
Applied but not yet confirmed if successful
Amount / $ / Name funding source

Other information

How did you hear about this DHS scholarship offer?

/

 Employer

/

 Colleague

/

 Other

 Course Provider

/

Nursing in Victoria website

Have you received a scholarship or funding from the Department of Human Services/Department of Health in the past?

/ Yes
No

If yes, record your Nurse Policy Branch identification number (if known)

If your name and/or address were different than that stated in criterion 1at the time of payment, please record these details so that scholarship payments can be expedited.

Declaration of applicant

To the best of my knowledge the information I have provided is true and correct. I have read the Guidelines for Applicants and agree to the conditions for successful applicants. I understand that scholarships are allocated at the discretion of the Department of Health and that the decision of the Department is final.
Applicant Name: / Signature: / Date:
/ / 20__

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