Rural Allied Health CPD Application and Evaluation Form

Applicant Details -

Title:

Full name

Address

Postcode

Telephone

Email

Allied Health Discipline

Current position/ Job title

Current workplace – name and address

Eligibility

Is your profession listed in the guidelines under the eligible professions? Are you working in a rural location?

Did you undertake the training (CPD) in 2017-18 financial year? Have you paid for the cost of the training (CPD)?

Have you obtained funds from any other source for this training (CPD)? Did you cover the cost of the course?

YesNo

YesNo

YesNo

YesNo

YesNo

YesNo

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Rural Workforce Agency - Victoria Level 6, Tower 4 World Trade Centre 18-38 Siddeley Street, Melbourne Vic 3005

T: +61 3 9349 7800 F: +61 3 9820 0401 E: W: rwav.com.au ABN: 31 081 163 519

Training event (CPD) Details –

Title

Date(s) Theme

Organisers

Location

Expenditure – (Copy of original tax invoice/receipts required as evidence)

Registration fee

Car Travel (capped at 0.66c per KM)

Airfare Cost (capped at 75% of cheapest economy airfare via most direct route) Accommodation Costs (capped at $100 per night to cover duration of the course) Childcare Costs ($60 per day for up to 5 days per year)

Evaluation Questions –

Please provide a response for the following statements

Rating Scale 1= strongly disagree 2=disagree 3= neutral 4=agree 5= strongly agree

  1. Participation in this professional development activity has increased my jobsatisfaction

1 2 3 4 5

  1. The professional development activity provided an opportunity for me to interact with other professionals in my field, which I do not usually have the opportunity todo.

1 2 3 4 5

  1. The professional development activity has contributed to increasing my skill level and ability to implement evidence- based practice.

1 2 3 4 5

  1. I would recommend the CPD Subsidy Program to mycolleagues

1 2 3 4 5

  1. How did the CPD event enhance your knowledge within your role to address community health needs (50 words orless)
  1. How did you hear about thisgrant?

Declaration

I declare that the information provided for my CPD subsidy payment to be issued is true and correct.

Signature of Applicant


Date (DD/MM/YYYY)

Submission Please email completed applications to

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