The Steven Melynk Scholarship

The Steven Melynk Continuing Education AwardApplication Form

CONTACT DETAILS FOR THE AWARD ADMINISTRATOR

Postal Address:

Award Administrator

The Steven Melnyk Continuing Education Award:

AHSPO Inc.

C/- Judy Bart Procurement Department AHSPO Inc.

Southern Health Locked Bag 29 Clayton Victoria 3168

Email:

Website:

You MUST send the hard copy of your application form plus one (1) copy

Illegible applications will not be considered.

The information you provide in the Application Form is the only information that will beconsidered in the selection process. It is very important that you answer all questions andprovide all the required documentary evidence.

Do not bind your application in any way or put it in plastic sleeves or folders; a staple in thetop left hand corner is sufficient.

Please refer to the checklist on page 9 prior to submitting the application.

Background

The Steven Melnyk Continuing Education Award is anAHSPO initiative aimed at increasing the skills of Purchasing and Material Management personnel working in health care facilities in all states and territories ofAustralia.

The Continuing Education Award is funded by AHSPO Inc. Awards are not determined on academic record; it is hoped that recipients willmake a significant contribution to Healthcare Industry. Award funding should be considered a contribution/subsidy toward the total cost of theprogram. It is expected that applicants will meet some of the costs of the program themselves.

Selection Criteria

Awards will be granted on the recommendation of a selection committee and will be based on the following criteria:

1. Current and previous employment in healthcare
2. Demonstrated commitment to healthcare
3. Demonstrated relationship between the proposed study and current practice in healthcare
4. Professional development history; and
5. Provision of an accountable and appropriate budget (if applicable) to assist with the proposed course/conference attendance.

IMPORTANT INFORMATION

Applicants applying for anAward under this Scheme may apply for one (1) of the following:

1. Postgraduate-Continuing Education programs – appropriate programs include:

Educational study programs or courses, including relevant accredited tertiary level or TAFE level courses and structured placement programs that form a component of the course for the purposes of upgrading skills in clearly defined procurement areas. The program that the applicant intends undertaking in the next 12 monthsmust be directly relevant to employment in healthcare.

1. Conference attendance (either as a presenter or a delegate) - the conference that the applicant intends undertaking in the next 12 months must be directly relevant to procurement employment in healthcare.

Eligibility: to be eligible to apply for an award for a postgraduate program or conference applicants must be:

• Working in procurement within a healthcare facility within an Australian State or Territory; and

• Attending or planning to attend a conference in Australia, continuing or intending tocommence postgraduate study at an approved Australian Educational Institution in the next 12 months.

1. Honours—the applicant’s proposed research in their honours year of Procurement study must demonstrate a focus. The student can be studying full time or part time.

Eligibility: to be eligible to apply for a scholarship for honours Procurement study applicants must:

• Intending to undertake an Honours level Procurement course commencing or continuing in the next 12 months;

Application Process

Applicants must provide all relevant documents listed on page 9 of the Application Form. Do not send original documents as these will not be returned. Do not attach a resume or curriculum vitae.

Applicants are responsible for obtaining all necessary information and making all necessary arrangements for the postgraduate activity identified in the Application Form.

Successful applicants must formally agree to the Terms and Conditions of the Steven Melnyk Continuing Education Award.

Unsuccessful applicants are entitled to reapply in the following round of applications.

Late Applications

Applications must be submitted to AHSPO Inc. postmarked on or before the advertised closing date of30thSeptember each year.

Late or illegible applications will not be accepted except in extenuating circumstances. If youanticipate difficulties in submitting the Application Form by the closing date of 30th September please contact AHSPO Incat

Other Scholarship Information

Applicants who are awarded or have previously received an AHSPOAward administered by Association of Hospital Supply and Purchasing Officers are not eligible for a further scholarshipunder this schemeuntil a period of two years has lapsed. The twoyear period applies from the date on which the previous successful application was submitted. Pleasecontact the Award Administrator at r further clarification.

Award Payments and Tax

The Award Administrator is not able to offer tax or financial advice. For assistance with determiningthe taxation status of scholarships in your personal circumstances, recipients of Awards arestrongly encouraged to seek their own advice from Centrelink, the Australian Tax Office or aRegistered Tax Agent.

For further information please see ATO Class Ruling 2003/7.

SECTION A:

APPLICANT DETAILS

Title: ………………

Surname Name: ……………………………………………………………………………………….

First Given Name: …………………………………………………………………………………….

Second Given Name: ………………………………………………………………………………..

Home Address

Street: ……………………………………………………………………………………………………….

Town: ………………………………………………………………………………………………………..

State / Territory: ………………………………Post Code: …………………………..

Phone home: …………………………………….Phone work: ………………………..

Mobile: ……………………………………………..Fax: ……………………………………..

Email: ………………………………………………………………………………………………………..

Postal Address (complete only if different from the above)

Address: ……………………………………………………………………………………………………

Town:

State / Territory: ………………………………Post Code: …………………………..

Note: All official correspondence will be sent to your postal address.

Make sure that the contact details you provide us with are current. If we need to speak to youdirectly i.e. in person, then we will normally contact you by telephone during the usual businesshours of 0900 hrs (9am) to 1700hrs (5pm) Eastern Standard/Summer Time, Monday to Friday. If itis difficult for you to be contacted during these times, please provide details of how we may get intouch with you. Attach a separate sheet with explanatory details if necessary.

Question 1

Are you a working in Procurement in the Healthcare industry?

Yes,

No

SECTION B: EMPLOYMENT HISTORY

Question 2(a)

Who is your current healthcare employer?

Question 2 (b)

When did you commence working for your current employer?

____/______/_____

(Day) (Month) (Year).

You must attach an official letter from your current employer stating the length of youremployment.

Question 2 (c)

What is the title of the position you hold?

Question 2 (d)

What is your employer’s physical work location?

Street Address:……………………………………………………………………………………………………………..

Suburb/Town: ……………………………………….. State: ……………. Postcode: ……………………..

Question 3

Please provide details of your previous employment history of the past 5 years only.

Previous Employer: ………………………………………………………………………………

Dates employed: Date from …………………………Date to ……………………….

Position Held

1. ……………………………………………………………………………..

2. ……………………………………………………………………………..

3. ……………………………………………………………………………..

4. ……………………………………………………………………………..

5. ……………………………………………………………………………..

SECTION D: PROFESSIONAL DEVELOPMENT

Question 4

Please provide details of your educational qualifications and professional development activities ofthe past 5 years that you consider relevant.

Qualification / Activity Date Obtained

1. ………………………………………………………………………………………………………………………………….

2. ………………………………………………………………………………………………………………………………….

3. ………………………………………………………………………………………………………………………………….

4. ………………………………………………………………………………………………………………………………….

5. ………………………………………………………………………………………………………………………………….

Question 5

Applicants must provide details of an immediate workplace referee and one professional referee.

Referees will be contacted in the event of an application being short-listed for a scholarship. Finaldecisions on successful applications may be dependent on evidence provided by a referee.

Both referees you nominate in the section below must be working in or associated with the healthcare industry.

1. Immediate workplace supervisor

Name: …………………………………………………………………………………………………

Position: ……………………………………………………………………………………………..

Email: ………………………………………………………………………………………………….

Phone: …………………………………………………………………………………………………

2. Professional referee:

Name: …………………………………………………………………………………………………

Position: ………………………………………………………………………………………………

Email:…………………………………………………………………………………………………..

Phone: …………………………………………………………………………………………………

Question 6

Tick the relevant box to indicate the postgraduate education activity that you are planning to undertakein the next 12 months. Applicants may apply for one (1) activity only.

Tertiary level study,

a short course/workshop, or

Conference.

PART A

1: Postgraduate tertiary level study: you are not required to submit a budget.

Name of postgraduate-continuing education study: ……………………………………………………..

Name of university/course provider: ……………………………………………………………………………..

You must attach details from the accredited Australian University/course provider of the nominatedactivity.

Commencement date:__/__/____ Expected completion date:__/__/____

2: Short course/workshop: you must submit a budget for this activity.

Name of short course/workshop: ……………………………………………………………………………………

Name of provider/institution: ………………………………………………………………………………………….

You must attach details from the accredited course/workshop provider of the nominated activity.

Commencement date:__/__/____ Expected completion date: __/__/____

3: Conference attendance/delegate: you must submit a budget for this activity.

Name of conference: ……………………………………………………………………………………………………….

Name of conference provider: ………………………………………………………………………………………..

You must attach details from the conference provider of the nominated activity.

Conference venue in Australia: ………………………………………………………………………………………

Commencement date:__/__/____ Expected completion date: __/__/____

Note: funding will only be considered for costs incurred from 2010 onwards.

The course provider must be nationally accredited, nationally recognised or an accredited/professionalprivate educational provider. For example universities, registered training organisation (RTO)

PART B

Only applicants undertaking or planning to undertake Honours level procurement study tocomplete questions 1—4.

1. Are you continuing or commencing Honours level procurement study in the next 12 months at an accreditedAustralian university?

No Please complete Part A above and then continue to page 7.

Yes Please complete questions 2, 3 and 4 below.

Honours applicants must attach official documentation from the Dean or Head of University, supporting your Honours level procurement study.

2. Do you have previous or current involvement in healthcare industry?

No Please continue to question 3.

Yes Please list your current and/or previous healthcare involvement in the table below.

3. At what university are you undertaking or intend undertaking the Honours level procurement study?

University: ………………………………………………Campus: ……………………………………………….

4. When do you expect to complete your full time or part time Honours level procurement study?

Semester/study period: Year: 20 ______

Applicants undertaking Honours level procurement study are not required to provide a budget.

Please continue to page 8

SECTION F: DETAILS OF YOUR POSTGRADUATE CONTINUING EDUCATION ACTIVITY

All applicants are required to describe the relevance of the nominated activity to their procurement employment in healthcare industry and how it will directly benefit the workplace.

Please print in the spaces provided.

Please attach a separate sheet if insufficient space

SECTION H: BUDGET GUIDELINES

Tertiary level study only: you are not required to provide a budget.

The scholarship has a maximum value of up to $5,000 for one year full time study or two yearspart time study for procurement personnel studying for their Masters.

For all other tertiary level study the award has a value of up to $1,250 per semester for eachsemester of full time tertiary level study up to a maximum of $5,000 per applicant. Theaward for part time tertiary students will be offered on a pro rata basis e.g. up to $1,250 persemester for each semester of part time tertiary level study to a maximum of $5,000 perapplicant. Funding will only be considered for costs incurred from 2010 onwards.

Tertiary level study applicants only to continue to page 8

For all other courses/workshops and conference participation the Award provides financialassistance in the form of a scholarship worth up to a maximum of $5,000 per applicant. You arerequired to provide a budget (Page 7).Your budget should only request funding toward course/workshop/conference costs you expect to incur from 2010 onwards.

It is important that you read the guidelines below to assist you to complete the budgeton the following page correctly.

Be as specific as possible to the nearest dollar and provide details of the item/s for which you arerequesting financial assistance.

Financial assistance toward the following will be considered:

 Conference registration or course fees

 Travel (real costs of fuel and/or fares): up to 75 cents per kilometre if you are travellingin excess of 100 kms each way

 Accommodation (excluding meals): maximum of $140 per night

 Textbooks: up to a total of $500

 Equipment (excluding computers and computer software): up to $250

Funding will not be considered for:

 Course/workshop/conference costs incurred prior to 2010

 Overseas study

 Purchase of computers or associated software; internet fees, phone calls, photocopying,stationery or loss of income/wages.

 More than one (1) professional development activity

Short Course/Workshop/Conference applicants please complete the budget

Please read the budget guideline on page 6 before completing the budget below. Applicants applying for assistance towards a short course/workshop/conference who do not submit a budget cannot be considered.

Note: Tertiary level study applicants are not required to provide a budget.

Your budget should only include items for which you expect to incur costs in 2010 and should not exceed a total of $5,000.

Note: you must attach details of the short course/workshop /conference from the

accredited Australian course/conference.

SECTION H: BUDGET (cont)

ITEM

1. Conference registration orcourse fees

2. Travel (note: only if courseinvolves travel in excess of100km each way). For example:_ _ Kms X 75c X _ _ trips = $

DETAILS OF THE EXPENSE AMOUNT OF FUNDINGREQUESTED $

3. Accommodation (note: maxaward per night is $140).

For example:$140 X _ _ nights = $

4. Equipment: please itemise.(note: max award is $250)

5. Textbooks: please itemize (note: max award is $500)

Total items 1—5 Total amount of fundingrequested$

SECTION I: FOR OUR RECORDS

Question 8

How did you hear about The Steven MelnykContinuing Education Award? Thisinformation assists AHSPO in the advertising of the Scheme.

Please tick the appropriate boxes:

Colleague

Website Address of website

Work in healthcare

Other Please specify

This declaration is legally binding and indicates that you have, to the best of yourknowledge, provided true and correct information.

This declaration must be completed.

Declaration

I declare that:

The information I have supplied in this Application Form is true and correct in everyparticular.

I understand there are penalties which apply to providing false information.

I will advise the Award Administrator, in writing, within 14 days of any change in my

circumstances.

I understand that:

The information on this form is collected for the purpose of assessing eligibility and

selection for The Steven MelnykContinuing Education Award.

The information/data on this form may be used for the purposes of obtaining aggregated

information about the Award and that any information gathered for this purpose willnot identify me in any way.

I agree to:

Sign an acceptance agreement with AHSPO Inc.,if successful in my application for The Steven MelnykContinuing Education Award.Participate in promotional material that may arise from the Steven Melnyk Continuing Education Award.

Signature of Applicant:……………………………………

Name of Applicant:…………………………………………

Date: / /20

Signature of Witness:………………………………………

Name of Witness:……………………………………………

Date: / /20

Privacy Statement

Association of Hospital Supply and Purchasing Officers Inc. makes every effort to comply with InformationPrivacy Principles in the Privacy Act 1988.

SECTION J: DECLARATION

It is intended that all applicants will be advised in writing of the outcome of their application bythe1stOctober.

If you are awarded an award and you accept the offer, then you will be required to complywith the Terms and Conditions of the award and sign an acceptance form indicating that youagree to the Terms and Conditions of the Award.

You will also be required to apply to theAward Administrator in writing within 14 days, to make any variation to the study for whichfunding has been granted. Such a variation will need to be accepted by the Award Administrator.You will be notified of the Award Administrator’s decision regarding study variation in writing.

Successful applicants will also be requested to sign an Advertising and Publicity Declaration. AHSPO Inc. may want to release certain detailsabout you for the purpose of advertising and promotion of the Scholarship Scheme to the mediaand to its Members.

The details released would only be your name, suburb/region,State/Territory and information about your course or conference provider. Personal details suchas phone numbers, e-mail details or addresses would not be released.Award recipients may also be invited to participate in events that might be arranged with AHSPO Inc. in relation to the Continuing Education Award.

If you accept the offer of anaward but are unable to take up the nominated activityin that year, the award cannot be deferred. In this instance your award will beforfeited. You may apply as a new applicant for anaward in the following round ifrequired.

If you accept the offer of anaward, payment/s of the award funding will not commenceuntil the Award Administrator has received the signed acceptance of offer form, the completedbank details form, the completed confirmation of enrolment form and official documentaryevidence of confirmation of enrolment/registration for the approved activity.

Award funding (or part thereof) can be expected to be credited to the nominated bankaccount within one month of the Award Administrator receiving all the required documents.Award funding will only be paid to the successful applicant and not to an institution ororganisation.

If you are successful in receiving anaward your letter of offer will include the followingdetails: the total amount of funding awarded, the break-up of funding, a schedule of paymentdates for the award year and a letter explaining how and when payments are made.

SECTION K: GRANTING OF AWARDS

The checklist below will assist you in preparing your application.

Have you:

Given your name and contact details? (Page3)

Attached an official letter from your current employer stating as evidence of your current

employment in healthcare? (Page 3)

Given contact details for two referees? (Page 4)

Given details of your course/conference and attached information about

your activity from the course/conference? (Page 5)

If applicable, given details of your Honours level procurement course and attached official

documentation from the Dean or Head of University, supporting yourHonours level procurement study? (Page 5)

Completed an itemised budget? (Page 6)

(tertiary level study applicants are not required to provide a budget)

Signed and dated the declaration? (Page 8)

Had a witness sign and date the declaration? (Page 8)

Made a copy to send with your original Application Form and kept a copy for your records?(Send only one copy of the required documents)

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The Steven Melnyk Continuing Education Award