Nurse Scholarship 2018

Application Form

Applications close Friday, 17 November 2017

Please ensure that you have read the Nurse Scholarship Guidelines 2018prior to completing your application.

Complete this form and return it along with a letter of support from your current supervisor to:

Email:

Mail: Ashlee Taylor

Cancer Council Victoria

615 St Kilda Road

Melbourne VIC 3004

1. Personal details

First name: / Surname:
Postal address: / Postcode:
Phone: / Email:

2. Academic qualifications

Qualification:
Institution:
Year graduated:
AHPRA registration number:

Other qualifications:

Qualification / Institution / Graduated

3. Please provide details of your preferred course

Institution:
Course title:
Course coordinator’s name:
Course start date:
Course end date:
Total course cost: $
Have you enrolled in this course? / Yes / No / If yes, please attach evidence of enrolment
When do you estimate you will complete the course? (including all assessments)

NOTE: If you are successful in receiving a scholarship, payment will only be made upon Cancer CouncilVictoria receiving evidence of enrolment in your nominated course.

4.Employment details

Please provide details of your current employment:

Organisation/Practice:
Street address: / Postcode:
Postal address (if different from above): / Postcode:
Supervisor’s name:
Supervisor’s email:
Telephone: / Fax:
Which Department of Health Region is this organisation/practice located within?
Which Local Government Area is this organisation/practice located within?
Number of years in current position:
If you become a cervical screening provider would you be doing any of the following in your current practice?
a) Working with Aboriginal and Torres Strait Islander women / Yes / No
b) Working with women from culturally diverse background / Yes / No
c) Working with rural women / Yes / No
d) Providing an out of hours service / Yes / No
e) Providing an outreach service / Yes / No
f) Providing a free/ bulk billed service / Yes / No
Does your workplace currently:
a) Allocate time and facilities for a nurse cervical screening clinic? / Yes / No
b) Have nurse/s who are credentialled cervical screening providers? / Yes / No
c) Promote other cancer prevention screening services such as breast screening, bowel screening, HPV vaccination and/ or viral hepatitis screening and management / Yes / No
g) Work primarily with women with disabilities / Yes / No
h) Work primarily with women who have experienced sexual assault / Yes / No
i) Work primarily with women who have experienced FGC / Yes / No

5. Payment information

Are you seeking any other financial assistance to undertake this course?

No, self-funded
Yes: Please list details / Organisation / Amount
$
$

6. Previous funding from Cancer Council Victoria

Have you received funding from Cancer Council Victoria (throughPapScreen Victoria) in the past?

No
Yes, scholarship
Yes, grant
Other – describe

If yes, what year was it granted?

7. Additional information

7.1 Please provide a brief statement outlining why you are interested in working in the area of cervical screening and applying for a scholarship:

7.2 When you return this form, please attach a letter from your supervisor outlining:

  • Their support for you to undertake the course
  • Their commitment to support you in providing cervical screening at the service upon satisfactory completion of the course and certification
  • Their support for you to participate in a quality improvement activity

IMPORTANT NOTE: If you receive a scholarship from Cancer Council Victoria and do not successfully complete your Cervical Screening Test provider course, you will be required to refund the full amount of scholarship funding to Cancer Council Victoria.

8. Agreement

Name of applicant:
Signature:
Date:

In submitting this application form, I agree that I understand and will follow the conditions of funding as outlined in this document and the Nurse Scholarship Guidelines 2018if I am successful in obtaining a scholarship.

Cancer Council Victoria Nurse Scholarship 2018 - 1 -