This form is to be completed by a Registered Nurse/MidwifeLevel 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: CN/M ACSC / Permanent Status
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

Please find attached an application for reclassification from RN/M 1 to RN/M 2 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

The applicant must provide a written statement addressing the four reclassification indicators for either the Clinical Nurse/Midwife role or the Associate Clinical Service Coordinator 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 evidence in support of their submission that can be provided to the assessment panel if requested (please note that it is not necessary to attach the supporting evidence in the first instance).

For each criterion, the applicant should respond by considering two simple questions:

  1. What have I done in my nursing/midwifery practice to show that I meet this criterion?
  2. What evidence can I provide, if requested, to show that I meet this criterion?

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 1 - 2Page 1 of 2