This form is to be completed by a Registered Nurse/Midwife seeking reclassification (other than RN/M Level 1 seeking reclassification to Level 2) as provided by the Nursing/Midwifery (South Australian Public Sector) Enterprise Agreement 2010. Before completing the form, applicants should carefully read the “Registered Nurse/Midwife Reclassification Process Guidelines” for additional information.

The applicant must fully complete Part 1 and Part 2 of this application form before submitting it to their line manager.

The line manager is to complete Part 3 and provide a copy of the completed form to the applicant before forwarding the original to the Human Resources department within their health unit/region.

Part 1:Employee Details

Surname: / Employee Number:
Given Name(s): / FTE:
Current Classification: / Increment: / Classification Sought:
Health Unit/Service:
Ward/Unit/Division:
Contact No: / Email:

I confirm that I am currently a permanent employee

I confirm that I have 3 years full time equivalent post-registration experience

(5 years experience required for applicants seeking Level 5)

Please find attached an application for reclassification as per the Nursing/Midwifery (South Australian Public Sector) Enterprise Agreement 2010.

Employee’s signature:
Date:

Human Resource Department use only

Signature / Date
Receipt of Application
Panel Convened

Part 2: Assessment Against Reclassification Criteria

Applicants seeking reclassification to Level 3, 4 or 5:

The applicant must provide a written statement addressing the reclassification indicators for the level/role he/she is applying (e.g. if seeking reclassification to the Advanced Clinical Services Coordinator role, the applicant must only address the reclassification indicators for that specific level 4 role).

Applicants are to clearly illustrate how he/she meets each indicator, preferably in dot point statements. Up to a maximum of half a page for each criterion is to be attached to this application form. Applicants should refer to,and attach, all relevant supporting evidence.

Applicants seeking reclassification to Level 6 ONLY:

The applicant must provide a written statement addressing the relevant descriptors within the Work Level Definitions outlined within Appendix 7 of the Enterprise Agreement. Applicants should refer to, and attach, all relevant supporting evidence to clearly illustrate how he/she meets the core Level 6 descriptors as well as the relevant grade criteria (e.g. 6.1 or 6.2 etc).

Part 3: Line Manager’s Recommendation

To be completed by the applicant’s line manager.

I support/do not support (delete not applicable) this application for the following reasons:

Line manager’s name:
Line manager’s signature:
Contact details:
Date:

Line manager to:

Forward a copy of this document to the applicant;and

Forward the original document to the Human Resources department within the heath unit/region.

Application Form RN/M 3 and abovePage 1 of 2