Type Form Version: June 2008 Title: CAP Application Form

Transcription

1 APPLICATION FORM COMPETENCY ASSESSMENT PROGRAMME AT SDHB Privacy Statement Thank you for your interest in the Competency Assessment Programme (CAP) at Southland District Health Board (SDHB). The questions being asked in this Application Form are relevant to the nature and type of work undertaken in SDHB and comply with the rights and obligations under legislation, including the Immigration Act 1987, the Health and Safety in Employment Act 1992, and the Human Rights Act This information will be used by SDHB to assess your suitability for the Competency Assessment Programme applied for, and used for that purpose only. If you are approved a place on the Competency Assessment Programme at SDHB the 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): Address: 2. DEMOGRAPHICS (OPTIONAL) Gender: Male Female Ethnicity: Nationality: Page 1 of 5

2 Languages spoken fluently other than English: If you are proficient in the above languages, would you be prepared to be contacted for the purposes of interpretation? 3. WORK STATUS Length of time away from Nursing? Current Practising Certificate? Current Indemnity Insurance? Company Have you ever been an employee of Southland DHB and/or its predecessors? 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 any action pending which may impact on your ability to carry out the duties required in the Competency Assessment Programme? Is there anything that you are aware of that may impede your ability to carry out the duties and functions while on the Competency Assessment Programme? If YES, please elaborate: 4. OTHER Have you any criminal convictions or any criminal charges pending (apart from minor traffic offences)? If yes, please provide details including dates: Do you consent to Southland DHB undertaking a criminal record check if required? Page 2 of 5

3 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.? If yes, 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 Southland DHB undertaking a health check if required? Yes No Page 3 of 5

4 5. QUALIFICATIONS / SCOPE OF PRACTICE Nursing: Non Nursing: Reason for undertaking the Competency Assessment Programme: 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. APPLICATION Include with your application: Curriculum Vitae (including referees) Proof of New Zealand Registration (i.e NZ Nursing Council Registration Number) International English Language test results (if overseas applicant) Send application to: Rosalie Wright Nurse Educator Practice Development Team Southland District Health Board PO Box 828 Invercargill Page 4 of 5

5 Consents and Declaration: This information is being collected to enable the Southland District Health Board (SDHB) to assess your suitability for the Competency Assessment Programme at SDHB 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 Southland District Health Board. If you provide false or inaccurate information, this will be considered serious misconduct and may result in dismissal from the Competency Assessment Programme with Southland District Board. 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 Competency Assessment 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 SDHB in deciding whether to accept me into the Competency Assessment Programme. I also agree that if I am employed by SDHB in the future, this information and any other information I provide during the Competency Assessment Programme may be used for any matter related to my employment. I understand that if accepted onto the Competency Assessment Programme at SDHB I will be required to read and abide by the SDHB Code of Conduct. Signature of Applicant Date Page 5 of 5