SOUTHERN DISTRICT HEALTH BOARD

RETURN TO NURSING PROGRAMME

APPLICATION FORM

Privacy Statement

Thank you for your interest in the Return to Nursing (RTN) programme at Southern District Health Board (DHB) - Southland. The questions being asked in this Application Form are relevant to the nature and type of work undertaken in Southern DHB and comply with the rights and obligations under legislation, including the Immigration Act 1987, the Health and Safety at Work Act 2015, and the Human Rights Act 1993. This information will be used by Southern DHB to assess your suitability for the RTN programme applied for, and used for that purpose only.

If you are approved a place on the RTN programme at Southern DHBthe answers and statements in your Application Form will form part of your record on the programme and will be used for human resource management purposes.

1.PERSONAL DETAILS

Title: ______
Surname/Family Name:______
Given Names:______
Preferred Name:______
What other names are you known by? ______
(Please include maiden names)
Postal Address: ______
Phone (daytime): ______
Cellphone: ______
Phone (evening): ______
Email Address: ______

2.DEMOGRAPHICS (OPTIONAL)

Ethnicity:
Nationality:______
Languages spoken fluently other than English:
Would you be prepared to be contacted for the purposes of interpretation? Yes □ No□

3.WORK STATUS

Length of time away from Nursing? _____ yrs NCNZ Reg Number ______
Current Practising Certificate? Yes □ No □
Current Indemnity Insurance?Yes □ No □Company______
Have you ever been an employee of SouthernDHB and/or its predecessors?
Yes □ No □
If YES, please give brief details
______
______
Has the NZ Nursing Council (or an overseas equivalent) taken any disciplinary action against you in the past or is there anyaction pending which may impact on your ability to carry out the duties required in the Return to Nursing programme?
Yes □ No □
Is there anything that you are aware of that may impede your ability to carry out the duties and functions while on the Return to Nursing programme? Yes □ No □
If YES, please elaborate: ______
Have you engaged in any previous Competence Assessment or Return to Nursing Programme previously? Yes □ No □
If YES, please elaborate: ______

4.OTHER

Have you any criminal convictions or any criminal charges pending (apart from minor traffic offences)?
Yes □No □
If YES, please provide details including dates: ______
______
Do you consent to SouthernDHB undertaking police vetting?
Yes □No □
Please refer to the attached Position Risk Analysis when answering these questions.
Have you ever had significant time off work (within the last 2 years) as a result of an illness, injury or infection that may affect your ability to participate in the programme?
IfYES, please give brief details: ______
______
Are there any other conditions (physical, psychological, other) that may affect your on the job tasks,and performance or those of other people which we should be aware of?
______
______
Do you have, or have you had, any communicable disease that has required treatment or medical investigation (e.g. hepatitis B/C, Tuberculosis)? Please provide brief details, including immune status if vaccinated.
______
______
Are there any disability needs which will require accommodation if you are successful with your application?
______
______
Do you consent to SouthernDHB undertaking a health check if required?
Yes □No □

5.QUALIFICATIONS / SCOPE OF PRACTICE

Nursing:______
______
Non Nursing:______
______
Reason for undertaking the Return to Nursingprogramme:______
______
______
What theory / practical concerns do you have?
______
______
What is your intention on successful completion of the programme?______
______
______
Areas of Preferred Clinical Experience (number in order of preference)
Medical______Surgical______Paediatrics______
Rehab______Outpatients______Mental Health______
Hospice______Other______

6.FULLTIME OR PART-TIME PARTICIPATION

Please specify your preference as to whether you wish to complete the programme on a fulltime or part-time basis:
□Fulltime (this is 5 days a week for 5 weeks, totalling 200 hours)
OR

□Part-time (this is up to 3 months).

Please note - theory days are set and we require 100% attendance rate

7.CLINICAL WORK

It is important to note that there is no monetary or other compensation for any clinical work undertaken as part of the Return to Nursing programme.

NB: completing the RTN Programme does not guarantee employment at Southern DHB. Normal recruitment practices still apply.

8.RETURN TO NURSING PROGRAMME FEE

Fee

Once you have been approved for the Return to Nursing programme, you will be invoiced prior to the commencement of the programme.

9.APPLICATION

Include with your application:
  • Curriculum Vitae (including referees)
  • Proof of New Zealand Registration (i.e. Nursing Council New Zealand Registration Number)
  • Verification from Nursing Council New Zealand that a Competency Assessment Programme/Return to Nursing is required.
  • Self-photo from shoulders up on a plain background
Send application to:
Shelley McDonald
NETP/RTN Nurse Educator
Practice Development Unit
Southern District Health Board
PO Box 828
Invercargill
Or email documents to:

CONSENTS ANDDECLARATION:

This information is being collected to enable the Southern District Health Board (DHB) to assess your suitability for the Return to Nursing at Southern DHB and will be used for this purpose only. If you fail or refuse to provide the information requested, then your application will be rejected by the SouthernDHB. If you provide false or inaccurate information, this will be considered serious misconduct and may result in dismissal from the Return to Nursing programme with SouthernDHB.

I ______declare that, to the best of my knowledge the answers to the questions in my application are correct. I understand that if any false or misleading information is given or any material fact suppressed, I may not be accepted or if I am accepted in the Return to Nursing programme I may be dismissed and this may affect my eligibility to compensation from ACC(If applicable).

I acknowledge that the information I have given will be used by Southern DHB in deciding whether to accept me into the Return to Nursing programme. I also agree that if I am employed by Southern DHBin the future, this information and any other information I provide during the Return to Nursing programme may be used for any matter related to my employment.

I understand that acceptance will only be on granted once police vetting has been clearedand if accepted onto the Return to Nursing programme at Southern DHB I will be required to read, sign andabide by the Southern DHB Code of Conduct.

______

Signature of ApplicantDate

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