WBoP PHO General Practice Team Scholarship Application Form

WBoP PHO GENERAL PRACTICE TEAM SCHOLARSHIP APPLICATION FORM Please complete this form, print your answers on the application form using black or blue ink.

Please staple your application once in the top left hand corner. Do not send bound applications.

Send your application form to: General Practice Services Admin Western Bay of Plenty Primary Health Organisation PO Box 13225, Tauranga 3141 New Zealand The decision is final. No further correspondence will be entered into.

If you have any questions please contact your General Practice Liaison or email gpsadmin@wboppho.org.nz .

1. Personal Details Surname: _____________________________ First name: __________________________ Postal address: ____________________________________________________________ _________________________________________________________________________ Daytime telephone: ___________________Alternative contact number: _______________ Email address:_____________________________________________________________ Employer (General Practice):__________________________________________________

2. Programme of Study Name of conference / seminar / short course / paper/professional development activity (select): _________________________________________________________________________ Date/s of programme: _______________________________________________________ Name of provider: __________________________________________________________ Location of programme: _____________________________________________________ If this funding application is for a nursing post graduate paper, have you applied for HWNZ funding?

Yes

No

N/A

Is this a research project?

Yes

No

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3. Rationale for Study Please provide a statement below explaining how your programme of study / professional development activity: a) is relevant to primary health care; b) will enhance your ability to contribute to patient health outcomes for your enrolled population; and c) aligns to the Prioritisation criteria set out within the WBoP PHO Scholarship Information Sheet ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________

4. Programme-related Costs Total Scholarship amount you are applying for: ____________________________ Detail Course / Activity Cost: __________________ Travel: __________________ Accommodation: __________________________________________ Other costs (specify):________________________________________

5. Declaration of Other Funding Please provide details (including the dollar amount) of any other funding applications you expect to receive or have applied for to assist with this programme of study. Please state when you expect an answer about any other funding applications you have made. ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________

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6. Employer Support Are you a permanent or casual employee at the practice? _____________________ How many hours do you currently work at the practice? _____________________ Please have your employer complete the following: I __________________________________________ (the Employer) confirm that _______________________________________ (Name of Applicant) is 1. a staff member at this practice and 2. I fully support him/her to undertake the programme of study outlined in this application and agree to release him/her as negotiated to meet programme requirements and 3. _____________ _____ (practice name) agrees to contribute $_____________ (specify amount) towards the cost of this study / professional development activity.

Signed: ___________________________ Name:__________________________

Position: __________________________ Date: ___________________________

7. Privacy Act WBoP PHO will, in accordance with the provisions of the Privacy Act 1993, make available to the applicant on request, the personal information that it holds about the applicant and will make any appropriate corrections to that information, to ensure that the information which is held is correct.

8. Checklist Please ensure you have provided ALL of the following:     

Copy of your current Annual Practising Certificate (if applicable) Verification of New Zealand residency e.g. copy of passport or birth certificate Course, conference or paper content description Proof of acceptance into your chosen programme of study (if available) Curriculum Vitae that includes your primary health care experience

*refer to appendix 1 for CV format and content suggestions

9. Certification of Accuracy I confirm that the information supplied in support of my application is accurate at the date of signing and the supporting documentation is enclosed.

I undertake to notify WBoP PHO if I withdraw from my chosen programme of study before it is completed.

Applicant’s signature: ___________________________Date: ____________________

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APPENDIX 1: CURRICULUM VITAE TEMPLATE    

Your CV does not need to be lengthy but should include information relevant to your qualifications and training and your work experience.

Be consistent with headings, fonts and layout.

Make it as readable as possible Present it in a professional manner

This is a suggested format for a CV only.

Personal details

Name: Insert Your Name

Address: Insert Your Address

Contact details: Telephone: Mobile: Email:

Current work Insert Position Title

Position details:

Nursing or professional philosophy (optional) Might include:   

The theoretical model that defines your practice A statement about your commitment to working in partnership with Maori and how you include the Treaty principals in your day to day practice.

The importance you place on working with people to achieve mutually agreed outcomes

Qualifications Start with the most recent State the year you completed the qualification and the organisation / institution you studied at, for example: 2000 Bachelor of Nursing, Waikato Institute of Technology

Employment Start with your current employment situation and work backwards e.g.

2002 Practice Administrator, ABC Medical Centre

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Professional affiliations e.g.

Member New Zealand Nurses Organisation

Member PMAANZ

Other professional activities

Conferences attended Include or omit

Conference presentations as appropriate

Teaching & publications

Involvement in research and / or projects

Key Achievements

Personal Attributes

Professional Interests e.g.     

Consultation processes Nursing education and the development of the nursing role Service development and monitoring of service delivery (consumer satisfaction) Quality assurance activities Project management

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