HETI Rural Medical Trainee Scholarship & HETI Rural Travel and Accommodation Sponsorship

HETI Rural Medical Trainee Scholarship &
HETI Rural Travel and Accommodation Sponsorship Scheme

Application Form

HETI aims to consolidate and build on rural medical trainee workforce clinical skills and knowledge to ensure they are better aligned with and responsive to the needs of doctors in training, particularly those in rural settings. Through the HETI Rural Medical Trainee Scholarship and the HETI Rural Travel and Accommodation Sponsorship Scheme, HETI aims to support the recruitment, retention and skill development of medical trainees working in rural areas within the NSW public health system.
Applicants may apply for both the HETI Rural Medical Trainee Scholarship and the HETI Rural Travel and Accommodation Sponsorship Scheme, but will only qualify for one option of support. If successful, the applicant will be granted the option of support that is listed as the preferred option of support on their application.
Please complete this application form and ensure you have enclosed the following information:
ü Proof of Australian / New Zealand citizenship or permanent residency
ü Document confirming your current employment at a rural training facility for one year or greater
ü A letter from your employer confirming their support for the continuing professional development activity/event
ü Evidence of the relevant continuing professional development activity/event.
ü Quotes and/or receipts (minimum of two) for travel and accommodation expenses
ü HETI Electronic Fund Transfer (EFT) Payment Form
Applications should be submitted by 17 April 2016 to:
LATE OR INCOMPLETE APPLICATIONS WILL NOT BE ACCEPTED

ELIGIBILITY

ü Australian or New Zealand citizen or permanent resident

ü Employed under the Public Hospital Medical Officers Award with a contract of employment for one year or greater

ü Employment location in a rural area (ASGC-RA2-5) within the NSW public health system

ü Education and training activity supported by Network Director of Training or Line Manager

N.B.: Please refer to the HETI Rural Medical Trainee Scholarship and the HETI Rural Travel and Accommodation Sponsorship Scheme Guidelines before completing this application.

HETI Rural Medical Trainee Scholarship & HETI Rural Travel and Accommodation Sponsorship Scheme - Application Form

1. Personal Details

Title: / First Name: / Surname:
Other Names (if applicable): / Date of Birth: / /
AHPRA Registration No.: / Stafflink No.:
Street Address: / Suburb:
Postcode:
Mailing Address (if different from above): / Suburb:
Postcode:
Home Phone: Work Phone:
Mobile Phone:
Email:
Are you an Australian/New Zealand citizen or Australian Permanent Resident?
Yes ☐ No* ☐
*Note only Australian/New Zealand citizens and permanent residents are eligible to apply
Are you of Aboriginal or Torres Strait Islander descent?
Yes ☐ No ☐
☐ Attach proof of Australian/New Zealand citizenship/residency status

2. Employment and Training

Please outline the details your current employment:

Classification:
Position:
Speciality (if applicable):
Training Facility: / Hospital LHD
*Rural ASGC Category:
*Note only applicants with an employment location in a rural area (ASGC-RA2-5) are eligible to apply. (Please refer to http://www.health.gov.au/internet/otd/publishing.nsf/Content/locator)
☐ Attach evidence of current employment at a rural (ASGC-RA2-5) training facility for one year or greater – i.e. letter of offer from employer
☐ Attach evidence of education and/or training activity supported by Network Director of Training or Line Manager – i.e. letter of approval/support from employer/management

3. Scholarship and Sponsorship Scheme

3.1 I am applying for the following option of support:

☐ 1. HETI Rural Medical Trainee Scholarship (capped at $1,500-$4,000 – see guidelines)
☐ 2. HETI Rural Travel & Accommodation Sponsorship Scheme (capped at $750)
☐ Both categories above (please note that applicants can apply for both but will only qualify for one based on the option of support listed as preferred below)
Preferred option: 1 £ 2 £

3.2 Scholarship category (please see guidelines for full details of each category):
Please only select an option below if applying for the HETI Rural Medical Trainee Scholarship

☐ Essential requirement of current training program
☐ Non-essential requirement – identified as an individual or service skill gap
☐ Enhancing teaching, supervision, leadership and management skills
☐ Patient-centred activity or project

3.3 Provide all relevant documentation regarding the Continuing Professional Development (CPD) education and training activity/event:

Name of CPD Activity/Event:
Cost for CPD Activity/Event:
Location (if applicable):
Date(s):
Anticipated benefit of CPD education and training activity:
Any Other Relevant Information:
☐ Attach evidence/information of activity/event (i.e. information flyer or email from event organiser noting relevant details e.g. date, location, purpose and intended attendees of activity/event)

3.4 Other source(s) of funding for Continuing Professional Development (CPD) education and training activity/event:

Have you received/will you receive assistance/funding from your Employer/Other for the CPD Activity/Event?
☐ Yes Amount $ ______
☐ No

3.5 Are you currently receiving any scholarship or other form of financial support for education and training purposes?

☐ Yes – please specify: ______
☐ No

4. Travel & Accommodation Details

Please complete if applying for the HETI Rural Travel & Accommodation Sponsorship Scheme

Provide all relevant documentation regarding the travel requirements:
(i.e. air fare, rail fare, hire of rental car or estimate of travel (in km) if with private use of own motor vehicle):

Details of Travel Required (if applicable):
Estimated Travel Cost:
Details of Accommodation Required (if applicable):
Estimated Accommodation Cost:
Other Associated Travel Expenses:
Explanation if most cost effective option not chosen:
☐ Attach receipts for all travel expenses if applying retrospectively – If applying prospectively, please provide quotes (minimum of two per expenditure)
☐ Attach completed HETI Electronic Fund Transfer (EFT) Payment form

5. Rural training and practice

The following questions are for data collection only and are optional.

Did you complete the Rural Preferential Recruitment Program?

Yes ☐ No ☐ If yes, list location: ______
Prior to commencing your postgraduate training, did you live in a rural area (ASGC-RA2-5)?
Yes ☐ No ☐
If yes, for how many years have you lived in a rural area (ASGC-RA2-5)?
What are your accommodation arrangements during your current position?
☐ Provided by the hospital (no charge)
☐ Provided by the hospital (at a cost)
☐ Private rented accommodation
☐ Staying with family/friends
☐ Other ______
For your university medical training, please specify your student type:
☐ Commonwealth supported
☐ Commonwealth supported Medical Rural Bonded Scholarship (MRBSS)
☐ Commonwealth supported Bonded Medical Places Scheme (BMPS)
☐ Commonwealth Department of Defence sponsored
☐ Australian full fee paying student
☐ International full fee paying student
☐ Other (specify) ______
As a medical student, did you undertake 12 months or more of your training in a rural area?
Yes ☐ No ☐ If Yes, provide details:
Were you the recipient of a NSW Rural Doctors Network:
☐ Rural Resident Medical Officer Cadetship or
☐ Rural Resident Medical Officer Cadetship for Indigenous Students
Did you participate in the John Flynn Placement Program?
Yes ☐ No ☐ If Yes, year of participation:
Were you a member of a rural health club?
Yes ☐ No ☐ If Yes, provide details:

Describe your plans for future practice in rural NSW:

6. Declaration

£ I declare that the information I have provided in this application is to the best of my knowledge true and accurate.

£ I am aware I am bound by the NSW Health Code of Conduct (PD2012_018).

£ In signing this application I agree to the Scholarship & Sponsorship Guidelines which I have read and understood prior to completing this application.

£ I understand that checks on the accuracy of this information may be undertaken at any time. If my application is successful and I have been found to have supplied false or misleading information, I will no longer be entitled to the sponsorship support and I will be required to refund the money.

Applicant Name:
Applicant Signature:
Date: / /

SUBMIT COMPLETED FORM AND ALL REQUIRED ATTACHMENTS TO:

Ms Kate Reynolds of HETI Medical Portfolio via or via fax (02) 9844 6544

To be completed by HETI staff member processing application

Name:
Signature:
Position:
Date: / /
Application Outcome: ______