Elspeth Pearson Award
Elspeth Pearson Award
APPLICATION FORM
Closing date for nomination is FRIDAY 12 AUGUST 2016
Guide to completing this form
Applicants must read these instructions carefully before submitting an application.
- Prior to completing thisApplication Form, please read the accompanying Award Information and Eligibility Criteria information sheet.
- Applicants must submit an application on the prescribed form accompanied by a brief CV. The format of the application form must not be altered in any way. Applications are not to be hand written.
- The application form and supporting documents are not to be submitted bound or on coloured paper.
- Unless otherwise stated, or unless in exceptional circumstances, applicants must not have commenced their proposed professional development opportunity prior to the closing date of the applications.
- References identified in the application must be received by the closing date. It is the applicant’s responsibility to ensure this occurs. References received after this time will not be considered. It is essential that you inform the references that you have included them on your application and that references are received by the closing date.
- Applicants must forward their application and supporting documents in Microsoft Word or Adobe PDF format to the National Manager for Professional Development at the address/and or email address below no later than midnight on Friday 12 August.
Applications received after this date will not be considered. It is the applicant’s responsibility to ensure the application is received by the National Manager for Professional Development.
Sharna Dominish
National Manager, Professional Development
Occupational Therapy Australia
PO BOX 6921, Silverwater, NSW 2128
Phone: 02 9648 3352 | 0426 485 202
Email:
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Elspeth Pearson Award Application Form
Section A – Applicant’s DetailsSurname/Family Name / Click here to enter text. /
Given Name / Click here to enter text. /
Title / Click here to enter text. / Gender / Click here to enter text. /
OTA Membership Number / Click here to enter text. / AHPRA Registration Number / Click here to enter text. /
Full Postal Address / Click here to enter text. /
Phone Number (business hours) / Click here to enter text. / Mobile Number / Click here to enter text. /
Email Address / Click here to enter text. /
Current Position Title / Click here to enter text. /
Do you have any restrictions placed on your practice by a regulatory authority? / Yes
No / Comments
Click here to enter text.
Are any aspects of your practice under review? If yes, please provide details / Yes
No / Comments
Click here to enter text.
Section B – Qualifications and Employment
Please complete the following details relating to your present employment
Current Employer / Click here to enter text. /
Length of tenure / Click here to enter text. /
Please list your PREVIOUS postgraduate appointments in order, starting from the most recent:
Place of work / Positions Held / Date
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Please list below all your university qualifications and post graduate degrees, including the year of the award and institution, starting with the most recent
Qualification / Institution / Year
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Please detail any noteworthy academic achievements in your career to date
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Section C – Proposed Professional Development Opportunity
Please complete the following detail referring to your proposed professional development activity
Professional Development Activity / Click here to enter text. /
Proposed Commencement Date
Click here to enter text. / Proposed completion date (if applicable)
Click here to enter text.
Does this opportunity require you to travel? / Yes
If yes, is the required travel:
Interstate International / No
Proposal Outline
In 1000 words or less, please describe the form of professional development opportunity, explaining how this will enhance your clinical practice and what benefits will be obtained.
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Please provide the details of the organisation(s) or education facility that you propose to visit and information relating to the course or program that you propose to undertake that comprises the professional development opportunity.
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Proposed Budget Outline
Please provide a budget estimate of expenses, not exceeding $15,000.
Budget can include (but is not limited to) cost of workshop/course, travel expenses including flights and accommodation, etc.
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Section D - Referee Details
Please provide the name and contact details of Referee One
Referees are required to fill in the attached referee form
Name (Including Title) / Click here to enter text. / Click here to enter text. / Click here to enter text.
Position / Click here to enter text.
Contact Address / Click here to enter text.
Contact Phone Number (business hours) / Click here to enter text.
Email address / Click here to enter text.
Written reference attached? / Yes No
Please provide the name and contact details of Referee Two
Referees are required to fill in the attached referee form
Name (Including Title) / Click here to enter text. / Click here to enter text. / Click here to enter text.
Position / Click here to enter text.
Contact Address / Click here to enter text.
Contact Phone Number (business hours) / Click here to enter text.
Email address / Click here to enter text.
Written reference attached? / Yes No
Section E – Terms & Conditions
The awarded recipient’s application will be reviewed by the Occupational Therapy Australia (OTA) Elspeth Pearson Award Steering Committee.
All applications will be reviewed against the eligibility criteria and the successful applicant will be determined by the Steering Committee.
Successful applicants will be notified by letter from the Steering Committee and be required to submit a copy of the final plan for their program or travel prior to commencing the professional development activity
The applicant must hold an active OTA membership for the period of the award and up to 12 months after the award period.
Presentation of the Elspeth Pearson Award will be made at suitable professional forums of OTA such as the biennial National Conference or the Annual General Meeting
Successful applications will be required to provide a written report to the Steering Committee during or at the completion of the activity. In addition, verbal feedback may also be required on the outcome.
Successful applications may be required to report findings to the profession, for example at National or State Conferences or at relevant special interest group meetings.
I agree to these terms and conditions.
Section F - Signature
I certify that the information supplied in this application is true and correct. I understand that Occupational Therapy Australia may wish to verify this information with an institution or individual. I consent to such enquiries being undertaken as part of the Elspeth Pearson Award selection process. I have read the application terms and conditions for the award and agree to adhere to them.
Declaration: / By checking the box below, I declare that the information contained in this application is true and accurate.
Date: / Click here to enter text.
Section G – Your Personal Checklist
Application Form completed and attached
Referee forms provided to the nominated referees. Ensure referees are aware of the timeframe.
CV attached
Submitted to Occupational Therapy Australia
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REFEREE FORM ONEAddresses the applicant’s character as well as the relevance of the professional development opportunity and the potential benefits it would bring to the profession
Applicants Name / Click here to enter text.
The above named applicant has applied for the Elspeth Pearson Award.
Please complete, print, sign, and return in confidence one copy of this form to the below address by COB 12 August 2016.
National Manager, Professional Development
Occupational Therapy Australia.
PO BOX 6921, Silverwater, NSW 2128
OR
Failure to return the form by the closing date may adversely affect the application.
How long have you known the applicant? / Click here to enter text.
Do you believe the proposed professional development opportunity planned by the applicant satisfies the objective of the Elspeth Pearson Award, being to advance their clinical skills and expertise through access to a specific professional development opportunity?
Can you comment? / Click here to enter text.
State your views of the applicant’s ability and suitability to maximise the benefit of the award. / Click here to enter text.
Name (including title) / Click here to enter text.
Position / Click here to enter text.
Signature / Click here to enter text.
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REFEREE FORM TWOEmployer supporting the objectives of the professional development opportunity or from a senior member of OTA who has experience in the relevant field of learning or study.
Applicants Name / Click here to enter text.
The above named applicant has applied for the Elspeth Pearson Award.
Please complete, print, sign, and return in confidence one copy of this form to the below address by COB 12 August 2016.
National Manager, Professional Development
Occupational Therapy Australia.
PO BOX 6921, Silverwater, NSW 2128
OR
Failure to return the form by the closing date may adversely affect the application.
How long have you known the applicant? / Click here to enter text.
Do you believe the proposed professional development opportunity planned by the applicant satisfies the objective of the Elspeth Pearson Award, being to advance their clinical skills and expertise through access to a specific professional development opportunity?
Can you comment? / Click here to enter text.
State your views of the applicant’s ability and suitability to maximise the benefit of the award. / Click here to enter text.
Name (including title) / Click here to enter text.
Position / Click here to enter text.
Signature / Click here to enter text.
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