2012 APPLICATION FORM - Austin Health

Pleaseaffix apassportsize photoClinical Nursing Education DepartmentPractice Advancement Program (PAP)2012 APPLICATION FORMFull Time Program(Applications close 5pm Friday 9 th September 2011)Name: (Print) __________________________________ Employee No: ____________________(Same as payslip)Postal Address: (Print) __________________________________________________________________________________________________ Post code: ____________Phone: (Home) ________________________ (Mobile): ________________________Email address: (Internal) ________________________________________________________Please complete the following:(External) ________________________________________________________1. Are you a January or a February Graduate? January February2. List your 2011 Graduate Nurse Year placements:1 st ______________________ 2 nd ______________________ 3 rd ______________________3. Which PAP program are you applying for? (Tick one box only) General PAP – 2 six months rotations in general nursingor Cardiac PAP – Full 12 months in cardiac/thoracic nursingor Mental Health PAP – Full 12 months in MH nursingor A combined Mental Health& General PAP – 6 months in MH combines with 6months in general nursing1

*For General PAP applicants to complete*4. To assist us with planning two rotations, please provide three preferences for the areas in which youwould like to work. We will attempt to provide at least one rotation from your preferences, but thereis no guarantee.You can find a list of ward/experiences most likely available for 2012 PAP in the Austin Hub. Go tothe CNED website and click on PAP.1. ___________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________2. _______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________3. ______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________2

*For Cardiac PAP applicants to complete*5. State the reasons why you would like to do your PAP year in the cardiac/thoracic area._____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________6. If you are unsuccessful, would you like to be considered for the General PAP? Yes NoIf yes, please give three clinical placement preferences (if unsure refer back to the AustinHub, go to CNED and click on PAP for a list of ward/clinical experiences)1.________________________________2.________________________________3.________________________________3

*For Mental Health PAP applicants to complete*7. State the reasons why you would like to do your PAP year in mental health. If you have apreference for a particular area in mental health, please state your reasons for this (refer to Austin Hubfor a list of clinical experience in mental health).________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________8. If you are unsuccessful, would you like to be considered for the General PAP? Yes NoIf yes, please give three clinical placement preferences (if unsure refer back to the AustinHub, go to CNED and click on PAP for a list of ward/clinical experiences)1.________________________________2.________________________________3.________________________________4

9. RefereesPlease list two (2) referees who can be contacted from within Austin Health and who canprovide feedback relating to your clinical nursing performance. Please note that one (1) ofyour referees must be a NUM or ANUM.Suitable referees are: Nurse Unit Mangers (NUM), Associate Nurse Unit Managers (ANUM),Clinical Nurse Specialists (CNS), Clinical Support Nurses (Graduate Nurse Year & others),Preceptors and Nurse Educators.Referee 1Name: ________________________________________________________Position: ______________________________________________________Ward: ________________________________________________________Phone No: ______________________Pager No: _________________Referee 2Name: ________________________________________________________Position: _______________________________________________________Ward: _________________________________________________________Phone No: _____________________Pager No.: _________________*Send completed application form and GNY Requirement Sheet to:Vivian YongCoordinator, Practice Advancement Program (PAP)Clinical Nursing Education DepartmentLevel 4 Education CentreAustin TowerAustin HospitalPO Box 5555Heidelberg Victoria 30845