Nursing and Midwifery Sabbatical Leave
Application 2016
Leave must be applied for and approved
12 months before leave is due to be taken
Applicants are encouraged to submit applications electronically to:
If electronic submission is not possible, applications may be sent by mail to:
Professional Development Coordinator
Nursing & Midwifery Office
L3 /Bldg 6 Canberra Hospital
P.O. Box 11 Woden ACT 2606
Contact:
Nursing and Midwifery Office
Telephone: 6244 2147
Email:
Applicant details
Title:Family Name:
Given Name:
Home Contact Details
Postal Address:
Telephone:
Mobile:
Email:
Work Contact Details
Postal Address:
Telephone:
Mobile:
Email:
Current registration details
Do you have a current unconditional practicing certificate? YES / NO (Please provide evidence)
Australian Health Practitioner Regulation Agency (AHPRA) Registration Number: ______
Current employment details
Current position: ______
Current area of practice and work unit: ______
Length of time in current position (years/months): ______
Post qualification nursing/ midwifery experience (years): ______
Employment status (permanent/ casual/ fixed term contract): ______
Employment hours (full-time/ part-time):______
Have you been employed by ACT Health for a minimum of 2 years? YES / NO (please indicate)
Please include a recent copy of a payslip/letter with your application confirming your employment with ACT Health.
Previous Support from ACT Health
Have you received a nursing scholarship or funding from ACT Health in the past? YES / NO
Are you currently applying for a scholarship or professional development funding from another source to assist with your study? Eg. Employer, Nursing and Midwifery Board, professional body? YES / NO
If yes,
Name of source:Amount sought: / $
Have you been successful? / YES / NO
Details of Course
Name of course: ______
Name of Tertiary Institution: ______
Will you be studying full-time/ part-time? ______
Is the course face-to-face/ online/ by distance? ______
Course start date: ______
Anticipated completion date: ______
Details of commitment to specialty area of nursing practice
Describe your commitment to the specialty area of nursing practice for which sabbatical leave is sought and how this degree is relevant to the work area
Please attach documentary evidence to support your successful progression towards completion of course (eg: transcript of results)
Details of Sabbatical Leave Request
Has your Delegate approved leave 12 months prior to period of sabbatical leave requested: YES / NO
Date of intended sabbatical leave: From / / 2016 - / /2016
Please indicate type of leave requested: 6 weeks full pay 12 weeks half pay
Please attach approved Application for Leave Form.
Criterion 8 – Delegate recommendation
Delegate recommendationI am pleased to provide this recommendation for: (please print)
NAME: ______
CURRENT POSITION: ______
who has applied for sabbatical leave in order to undertake the following course:
(Insert title of the course and institution)
DELEGATES COMMENTS AND RECOMMENDATIONS:
As the Delegate of the above person, I support their education and their application for sabbatical leave. I am aware that Sabbatical Leave payments remain the responsibility of the applicants Division.
1 Yes
1 No
If No, please explain ______
Delegates name: ______
Position: ______
Signature: ______
(sent from work email, serves as an electronic signature)
Contact phone: ______
Contact email: ______
Date: ______
Criterion 8 – Referee recommendation
· the direct manager, CNC/CMC or nurse/midwife in charge of the ward/unit/department/centre in which the applicant is currently working; or
· the direct manager or nurse/midwife in charge of the division/section/program.
I am pleased to provide this recommendation for: (please print)
NAME: ______
CURRENT POSITION: ______
who has applied to ACT Health for sabbatical leave in order to undertake the following course:
(Insert title of the course and institution)
REFEREE’S COMMENTS AND RECOMMENDATIONS:
As the supervisor of the above person, I support their education and their application for Sabbatical leave.
1 Yes
1 No
If No, please explain ______
Referee’s name: ______
Position: ______
Signature: ______
(sent from work email, serves as an electronic signature)
Contact phone: ______
Contact email: ______
Date: ______
Declaration
To the best of my knowledge the information I have provided is true and correct. I understand that sabbatical leave is allocated to twelve employees at any time, that selection is at the discretion of ACT Health and that the decision of ACT Health is final.
Applicant name: ......
Signature: ......
(Sent from work email, serves as an electronic signature)
Date: ......
Check list for Nursing and Midwifery Sabbatical Leave Application.
o Completed Nursing and Midwifery Sabbatical Leave Application Form.
o Evidence current unconditional nursing registration.
o A copy of a payslip/letter (from Nursing recruitment, Human Resources etc) confirming employment with ACT Health and current designation.
o Transcript of Results/documentary evidence of course progress to date.
o Completed Application for Leave Form (completed 12 months prior to period when leave is sought)
o Delegate’s Recommendation to support the application.
o Referee’s Recommendation to support the application.
o Signed Declaration.
Please Note: incomplete applications will not be considered. It is the responsibility of the applicant to ensure all documentation is attached.
Applicants are encouraged to submit applications electronically to:
If electronic submission is not possible, applications (marked CONFIDENTIAL) may be sent by mail to:
Professional Development Coordinator
Nursing & Midwifery Office
L3 /Bldg 6 Canberra Hospital
P.O. Box 11 Woden ACT 2606
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