Postgraduate Programs:Variation to PEP Support Form
Please complete this form as far as possible in Word. You may print out the form for signatures.
Please use this form to notify the PEP Unit of any additional information or changes to your Professional Experience Placement (PEP).
If you have submitted a PEP Support Form more than one year ago please use this form to confirm your placement details prior to the start of the semester you are due to commence your placement.
1. Your Details
Flinders Student ID:(if known) / Title:
(Mr, Mrs, Ms, Dr)
Given Name: / Family Name:
I am confirming or changing my placement details in the following Professional Experience Placement topic(s):
Topic Code: / Topic Name:Year: / 20______/ Semester:
(please tick) / ☐One ☐ Two
Topic Code: / Topic Name:
Year: / 20______/ Semester:
(please tick) / ☐One ☐ Two
This placement is:(tick all that apply)
☐An observational placement
☐A self-negotiated placement
☐A Work Integrated Learning (WIL) placement with my new employer
☐Under the supervision of a preceptor
☐A supernumerary placement
2. Employer or Clinical Venue Confirmation or Change
(If applicable)I will no longer be attending my placement(s) at:
Please use full names rather than initials.
Venue name:I confirm that my placement will take place in the following venue:
Please use full names rather than initials.
Venue name:Venue address:
Venue phone:
(include area code)
Venue contact person:
If your venue has changed, you are required to show evidence that your current employer/Clinical Manager/proposed host venue Manager will support your completion of the clinical practice components of the course.
To be completed by the venue:
As the Clinical Manager supporting the student, my details are as follows:
Please use full names rather than initials.
Clinical Manager’s NameTitle:Clinical Manager’s Role:
Clinical Manager’s Phone Number:
(include area code) / ( ) / Clinical Manager Email:
Ward/Region/Team of Employment:
Organisation’s Name in full:
Is this student employed at this venue? / ☐Yes ☐No
Organisation’s Street Address:
Organisation’s Mailing Address:
(if different to above)
ABN (Private organisation only):
Proposed placement dates:
I agree that the required support will be provided to the applicant to undertake the professional experience placement components of the course within this workplace (please tick):
☐Provide the required number of placement hours in the designated nursing environment
☐Allocate or assist with the choice of preceptor(s) in the clinical area
☐Supervision in and assistance with acquisition of clinical skills
☐Provide guaranteed support for the entirety of the agreed placement duration
Clinical Manager’s Signature:(or equivalent) / Date:
Director of Nursing or Designated Proxy / Date:
3. Mentor /Preceptor Details
(If applicable)The following mentor(s) / preceptor(s) are to be removed:
Name of Mentor / Preceptor:Name of Mentor / Preceptor:
The following mentor(s) / preceptor(s) are to be added:
Mentor / Preceptor 1
Please use full names rather than initials.
Name and Title:Position and Role Title:
Service / Department:
Organisation in full:
Qualifications:
Telephone:
(include area code) / ( ) / Mobile:
Email:
Mentor /Preceptor 2
Please use full names rather than initials.
Name and Title:Position and Role Title:
Service / Department:
Organisation in full:
Qualifications:
Telephone:
(include area code) / ( ) / Mobile:
Email:
Mentor /Preceptor 3
Please use full names rather than initials.
Name and Title:Position and Role Title:
Service / Department:
Organisation in full:
Qualifications:
Telephone:
(include area code) / ( ) / Mobile:
Email:
4. Important Additional Requirements
It is essential that the following arrangements are in place before you may commence your placementeven if the placement is within your own workplace:
- An Affiliation Agreement between your host venue and the University must be in place before you can commence your placement even if your host venue is also your employer. If an agreement is not in place it can take up to eight weeks for this legal process to be completed. The University undertakes this process for you and we ask that you submit this form as soon as possible to ensure that we can conduct these negotiations before you are due to commence your placement(s). The University will advise you if you need to delay your placement whilst an Affiliation Agreement is negotiated and advise you when you are able to commence your placement once it is in place.
- The Professional Experience Placement Unit must receive evidence that you comply with all the Pre-placement Requirements as outlined on the Student Responsibilities page of the Postgraduate PEP website before a placement can be undertaken. Please refer to:
5. Applicant’s Declaration
- I agree that the School of Nursing & Midwifery may contact the venues/host venue I have detailed here, if there are questions regarding the placements I have nominated.
- I consent to the School of Nursing & Midwifery providing my nominated preceptors with my contact details prior to the commencement of my placement.
- I acknowledge that if I fail to provide all required documentation in a timely manner prior to my placement I may be required to withdraw from the topic. If this occurs beyond the census date for the topic(s), then penalties (including financial costs for the topic) will be incurred by me.
- If I decide to withdraw from my topic enrolment(s), I will do so via the Student Information System prior to the census date for the topic(s).
- I have read and understood part 4. Important Additional Requirements and accept School of Nursingand Midwifery pre-placement requirements.
Applicant’s Signature: / Date:
6. Submitting This Form
Scan and email the completed form to the Professional Experience Placements Unit . A return email will confirm satisfactory receipt of your documentation.
Alternately, you may post the completed form to:
PEP Coordinator (Postgraduate)
Professional Experience Placements Unit
School of Nursing & Midwifery
Flinders University
GPO Box 2100
ADELAIDE SA 5001
Postgraduate Programs: Variation to PEPSupport Form V 20170202Page 1 of 4