Professional Experience Placement (PEP) Support Form:
Diabetes Management and Education
NURS8732 Diabetes Practicum–Non Semester 2
Please type information into form as far as possible and then print out for signatures.
In order to plan for your Professional Experience Placement (PEP) the School of Nursing & Midwifery requires details of your proposed placement(s) and venue(s).
1.Your Details
Please provide your full names rather than initials
Flinders Student ID:(if applicable) / Title:
(Mr, Mrs, Ms, Dr)
Family Name: / Given Name(s):
Home Telephone Number:
(include area code) / ( ) / Mobile Number:
Email Address:
Mailing Address:
2. Your Program of Study
I have been admitted into:
☐Graduate Certificate in Primary Health Care (Diabetes Management and Education)
☐Graduate Diploma in Nursing (Diabetes Management and Education)
☐Master of Nursing (Diabetes Management and Education)
Please see relevant Study Plans to assist with topic selection.
3. Professional Experience Placement (PEP) requirements
As a postgraduate Diabetes Management and Education student you are required to complete a 40 hour observational placement in a Diabetes Centre anywhere in Australia as part of topic NURS8732 Diabetes Practicum (PEP). You will be required to negotiate this placement at your chosen venue. We encourage you to do placements in a large centre which provides multi-disciplinary education for people with type 1, type 2 and gestational diabetes as this is a requirement of the accreditation from ADEA.
- Employer/Clinical Venue Support
You are required to show evidence that your Clinical Manager or proposed host venue manager will support your completion of the PEP components of the course. It is essential that this section be signed by your employer or host venue/clinical manager before you submit this form.
To be completed by your Clinical Manager/host venue manager:
As Clinical Manager/host venue manager, please complete the section below as evidence that your venue will support the completion of the clinical practice components of the course for this applicant.
Please provide full names rather than initials.
Clinical Manager’s Name & Title: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 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 40 hours in total of observational placement in a Diabetes Management and Education environment
☐Allocate or assist with the choice of preceptor(s) in the clinical area
☐Supervision in and assistance with acquisition of clinical skills using the competency standards, PEP Record, Blood Glucose Accreditation and a teaching session
☐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:
5. Preceptor Details
The School requires the details of at least one preceptor who will support your placement(s) for every venue. It is strongly advised that your preceptor(s) are Credentialled Diabetes Educators (CDEs). If there is no CDE available, you are advised to contact the Topic Coordinator for assistance.
Preceptor 1 – please provide full name rather than initials
Name and Title:Position and Role Title:
Service / Department:
Organisation in full:
Qualifications:
Telephone:
(include area code) / ( ) / Mobile:
Email:
Preceptor 2 - please provide full name rather than initials
Name and Title:Position and Role Title:
Service / Department:
Organisation in full:
Qualifications:
Telephone:
(include area code) / ( ) / Mobile:
Email:
6. Important Additional Requirements
It is essential that the following arrangements are in place before you commence your placement even 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:
7. 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 Section6. Important Additional Requirements and accept the School of NursingMidwifery’s pre-placement requirements.
Applicant’s Signature: / Date:
8. Submitting This Form
Please scan and email the completed form . A return email will confirm satisfactory receipt of your documentation.
It is recommended that you retain a copy of the completed document for your records.
PEP Support Form: Diabetes Management and Education: NURS8732 (Version 3.0)Page1 of 3