SCIENCE
School of Psychology
UoA Student ID:
APPLIED BEHAVIOUR ANALYSIS
Post Graduate Diploma in Applied Psychology
Supplementary Application Form
Complete and forward this form and other requested material by the 1st of December.
Post to:
The ABA Selection Panel
University of Auckland
School of Psychology
Tāmaki Innovation Campus
Private Bag 92019
Auckland Mail Centre 1142
New Zealand
Email to:
psych-admintamaki@auckland.ac.nz
Personal
delivery/
courier to:
The ABA Selection Panel
School of Psychology
Building 721, Room 321
Tāmaki Innovation Campus
261 Morrin Road, St Johns
Auckland
New Zealand
NOTES:
1.
2.
3.
4.
1.
Pease read the “Information for Applicants to start in 2015” on the following link before completing this form.
http://www.psych.auckland.ac.nz/en/for/future-postgraduates/fp-admission-and-enrolment/fpapplicationforms.html#4a4bd0aa498c8c01a4bdfdcc0401d3bf
Please complete online application for PGDAP using the following link: https://www.auckland.ac.nz/en/about/apply-nowpage.html. Please make sure you complete “Intended courses” section (PSYCH 720A/B, 730, 757 & 651A/B) so the Professional
staff know which Psychology programme you are applying to. If you need help, please send your request to
scifac@auckland.ac.nz.
Please complete this form by typing the answers in the required fields, print it out, physically sign, and either scan and email, or
post the signed form to the appropriate address as above.
A letter informing you of the selection results will be sent to your email contact address before the 20th of December.
PERSONAL INFORMATION
Full Name
Contact Address
(1 December 2015 – 1 March 2016)
Contact phone numbers
Email address
Ethnic identity
NZ/Australian citizenship/residency
Yes/NZ/AUS/No
(delete irrelevant)
Gender (delete irrelevant)
2.
Male/Female
ACADEMIC QUALIFICATIONS
Applicants who completed their previous tertiary study at The University of Auckland need not attach any documentation. All others must
attach a copy of their official Academic records to be considered for the programme.
Degree
Major
Institution
Years of attendance
1
SCIENCE
School of Psychology
UoA Student ID:
APPLIED BEHAVIOUR ANALYSIS
Post Graduate Diploma in Applied Psychology
Supplementary Application Form
Please list all courses that had a behaviour analytic component (i.e. behavioural modification,
behaviourism, operant behaviour, respondent behaviour, experimental analysis of behaviour, or
applied behaviour analysis).
Year
3.
Institution
Grade
Obtained
Course Title
Hours of
Behavioural
Lectures
WORK EXPERIENCE
List all the jobs you have had, full or part-time, paid or voluntary where behaviour-analytic services have either been, or could have been
provided.
Dates
Employer
Position
Description of duties
Are you presently employed by an agency, company, or organisation in a role where you have the
authority to design and implement behaviour-analytic programmes? (delete irrelevant)
YES/NO
If YES, name your employer and job title, and describe your duties in the table above
Have you previously received any supervised or mentored practical experience that meets the
Behaviour Analyst Certification Board requirements? (delete irrelevant)
YES/NO
If YES, describe that experience and provide supporting documents
2
SCIENCE
School of Psychology
UoA Student ID:
APPLIED BEHAVIOUR ANALYSIS
Post Graduate Diploma in Applied Psychology
Supplementary Application Form
4. INTENDED ENROLMENT DETAILS & PROFESSIONAL CREDENTIALS
I intend enrolling (delete irrelevant)
FULL/PART-TIME (discuss with the Director of ABA programme)
If you are offered a place in the Year 3 ABA courses, and successfully complete the requirements of those
courses, which of the following professional credentials do you intend pursuing? (delete irrelevant)




Board Certified Behaviour Analyst
Registered Psychologist in New Zealand
No certifications will be sought
Other (please specify)
Particular problems that some people have, or have had, may impair their ability to work as a
Behaviour Analyst and Psychologist. You may choose to provide this information on this form or in
person/writing to the Director of ABA Programme. Disclosure of such problems may or may not affect
your selection, but if you are selected and such factors are later discovered, it may affect judgements
about your professional suitability.
Have you acted violently towards another person?
YES/NO
If YES, explain below.
Do you currently have, or have had, problems associated with alcohol or drug use?
YES/NO
If YES, describe the steps you have taken to change and address these problems.
Do you currently have, or have had, problems with health or well-being (physical and/or psychological)
that may impact on your ability to train and/or work as a Behaviour Analyst/Psychologist?
YES/NO
If YES, describe the steps you have taken to manage these problems.
Do you have any criminal convictions?
YES/NO
If YES, describe.
3
SCIENCE
School of Psychology
UoA Student ID:
APPLIED BEHAVIOUR ANALYSIS
Post Graduate Diploma in Applied Psychology
Supplementary Application Form
5.
INTERESTS IN APPLIED BEHAVIOUR ANALYSIS
Have you read the information offered on the Behaviour Analyst Certification Board® Inc. website at
www.bacb.com? (delete irrelevant)
YES/NO
Is there any reason why you might be ineligible for the BACB® examinations (BCBA or BCABA) or
NZPB registration once you have completed your intended programme of study? (delete irrelevant)
YES/NO
if YES, describe that reason.
With which group(s) and which setting(s) are you interested in working as a Behaviour Analyst once
you have completed your intended programme of study? (no more than 50 words)
What advantages do you believe are accrued by a behaviour-analytic approach to working with the
group(s) you have identified above? (no more than 50 words)
Are there any group(s) for which behaviour-analytic services might be offered but with which you are
unwilling to work?
YES/NO
if YES, identify the group(s).
Identify the personal qualities and academic abilities that would likely to help you become a qualified
and effective behaviour analyst? (no more than 100 words)
After completing the 3rd year wold you be interested in doing a PhD in Behaviour Analysis? If so what
area(s) of behaviour analysis would you be interested in? (no more than 50 words)
4
SCIENCE
School of Psychology
UoA Student ID:
APPLIED BEHAVIOUR ANALYSIS
Post Graduate Diploma in Applied Psychology
Supplementary Application Form
5.
INTERVIEW
A selected number of applicants will be interviewed on the 10th of November. Will you be available at
this time to attend an interview? (delete irrelevant)
YES/Skype/NO
6. REFEREES
The Referees should not be family members. Preferably, at least one referee should be from an employer or previous work supervisor.
Name
Postal Address
or Email
Phone
Relationship
Name
Postal Address
or Email
Phone
Relationship
You must sign the following statement concerning Referee’s requests. The School of Psychology requests your permission to contact your
referees if they consider it necessary. The purpose of contacting referees will be to ask them about your academic aptitude, research skills,
personal skills, and your suitability for admission and potential success in the programme.
I agree that the School of Psychology may contact the above Referees for the purposes described
above.
Signature:
Date:
7. DECLARATION
I declare that the information I have given in this application form is true and accurate. If
statements I have made are found to be false or inaccurate, I acknowledge that my application may
not proceed.
Signature:
Date:
5
SCIENCE
School of Psychology
UoA Student ID:
APPLIED BEHAVIOUR ANALYSIS
Post Graduate Diploma in Applied Psychology
Supplementary Application Form
CHECKLIST
I have read “ABA Information for Prospective Applicants”.
I have submitted online application including “Intended courses”.
I have typed the relevant information on the form (no handwriting).
I have physically signed all relevant parts of the form.
I have enclosed all Academic record(s) (for graduates of the institutions other than the
University of Auckland).
I have enclosed the documents supporting any previous supervised or mentored practical
experience that meet the Behaviour analyst Certification Board requirements (if applicable).
6