SCHOOL OF PSYCHOLOGY
APPLICATION FORM FOR POSTGRADUATE DIPLOMA IN APPLIED PSYCHOLOGY
SPECIALISING IN APPLIED BEHAVIOUR ANALYSIS
FOR 2015
Complete this form and other requested material by 1 November 2014
By mail, send to ABA Selection Panel, School of Psychology (Tāmaki Campus), The University of Auckland, Private Bag
92019, Auckland 1142, New Zealand,
Or if delivering in person or by courier, please take to School of Psychology, Building 721, Room 321, Tāmaki Campus,
Corner Merton and Morrin Roads, Glen Innes, Auckland 1702
NOTES
1. Please read the document titled ‘Postgraduate Programmes in Applied Behaviour Analysis: Information for
Prospective Applicants’ before completing this form.
2. You should complete this form if your intention is to enrol in the three Year 3 courses and the Practicum of the ABA
programme.
3. In addition to completing this form, you must apply online (i.e. using Student Services Online) for enrolment in the
PGDipAppPsych specifying PSYCH 730, 757, 720 and 651 as your preferred courses. If you need help with this, contact
psych-admintamaki@auckland.ac.nz . Students from outside New Zealand should contact the International Students
Office at international@auckland.ac.nz. For information about fees, contact fees@auckland.ac.nz.
4. Please either download and complete an electronic copy of this form, or write legibly with a black pen.
5. Your application form is confidential to the ABA selection panel and will be shredded if you are not selected.
1. PERSONAL INFORMATION
Full name
University of Auckland ID No (if known)
Permanent Home Address
Contact Address
(1 November 2014 – 1 March 2015)
Telephone
Home:
Mobile:
Email address
Ethnic identity
Gender
Male
Female
2.
PREVIOUS TERTIARY STUDY
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 transcript to be considered for selection. The section
on recognition of previous tertiary study on the Student Services Online application must also be completed in full.
3.
CITIZENSHIP / RESIDENCY INFORMATION
Do you have New Zealand citizenship or status as a permanent resident in New Zealand?
YES
NO
4.
INTENDED ENROLMENT DETAILS AND PROFESSIONAL CREDENTIALS
a.
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?
Board Certified Behaviour Analyst
Registered Psychologist in New Zealand
No certifications will be sought
Other (please specify)
b.
In which courses do you intend enrolling? (Note: when applying on Student Services Online, apply for the degree
programme (e.g. PGDipAppPsych). There will be a prompt for you to then complete the Postgraduate Worksheet.
PLEASE COMPLETE THIS. Please also list in the table below the courses in which you would like to enrol in 2015 as
this will be compared with the Postgraduate Worksheet on Student Services Online. After selection you will be
notified when to enrol into your approved courses on Student Services Online. Ensure that the total number of
points is equal to, or greater than, that required for the degree in which you intend enrolling).
Course Number
Course Title
Point Value
5.
ACADEMIC QUALIFICATIONS
a.
Qualifications Earned: List in the table below all those degrees and certificates that you have earned from any
institution offering tertiary education.
Year
b.
a.
Qualification
Courses Passed: List all those courses for which you have received credit and that had some behaviour analytic
component. As well, provide an estimate of the total number of lecture-hours from each of these courses that
were ‘behavioural” (i.e. behaviour modification, behaviourism, operant behaviour, respondent behaviour,
experimental analysis of behaviour, or applied behaviour analysis).
Year
6.
Institution
Institution
Course Title
Grade
Obtained
Hours of
Behavioural
Lectures
RELEVANT WORK EXPERIENCE
List jobs you have had where behaviour-analytic services have either been, or could have been provided. Note
whether these jobs have been full-time or part-time, paid or voluntary. (Append additional sheet if necessary).
Dates
Employer
Position
Description of Duties
b.
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?
Yes
No
(tick one)
If you answered “yes”, name your employer and job title, and describe your duties
c.
Have you previously received any supervised or mentored practical experience that meets the Behaviour
Analyst Certification Board© requirements?
Yes
No
(tick one)
If you answered “yes”, describe that experience and provide supporting documentation
7.
INTERESTS IN APPLIED BEHAVIOUR ANALYSIS
a.
Have you read the information provided in Information for Prospective Applicants, and have you read the
Behaviour Analyst Certification Board© Inc, website at www.bacb.com, and have you read the NZPB website?
Yes
b.
No
(tick one)
Is there any reason why you might be ineligible for the Board Certified Behaviour Analyst examination or
NZPB registration once you have completed your intended programme of study?
Yes
If you answered “yes”, describe that reason
No
(tick one)
c.
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? (Describe in fewer than 50 words)
d.
What advantages do you believe are accrued by a behaviour-analytic approach to working with the group(s)
you have identified above? (Describe in fewer than 50 words)
e.
Are there any groups for which behaviour-analytic services might be offered but with which you are unwilling
to work?
Yes
No
(tick one)
Identify those groups if you answered “yes”
f.
Identify those personal qualities and academic abilities that would likely to help you become a qualified and
effective behaviour analyst? (Describe in fewer than 100 words)
g.
After completing your thrid yeat would you be interested in doing a PhD in Behaivour Analysis? If so what
area(s) of behaviour analysis would you be interested in. (Describe in fewer than 50 words)
8. AVAILABILITY FOR INTERVIEW
A selected number of applicants will be interviewed on 10th November 2014. Will you be available at this time to
attend an interview if the Selection Panel requests one?
Yes
Yes (via teleconference)
No
(tick one)
9. Particular problems that some people have, or have had, may impair their ability to work as a behaviour analyst and
psychologist. Please tell us if:
(a) You have acted violently towards another person (and if so, what steps you have taken to change and address
this problem).
YES / NO (delete one). If yes, explain in person or in writing to ABA Programme Director.
(b) You currently have, or have had, problems associated with alcohol or drug use (and if so, what steps you have
taken to change and address these problems).
YES / NO (delete one). If yes, explain in person or in writing to ABA Programme Director.
(c) 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 (and if so, what steps you have
taken to manage these problems).
YES / NO (delete one). If yes, explain in person or in writing to ABA Programme Director.
(d) You have any criminal convictions.
YES / NO (delete one). If yes, explain in person or in writing to ABA Programme Director.
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 .
10. REFEREES
Who can we contact to ask about your suitability for this programme of study? These people should be either previous
or current lecturers or employers, and should know you well. Please note what your relationship with each person is or
was. Ensure you obtain their agreement to serve as a referee for you.
Name
Postal Address
Referee No.1
Phone & Email
Phone:
Email:
Relationship
Referee No.2
Phone:
Email:
Relationship
You must sign the following statement concerning referee’s reports:
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, your suitability
for admission, and potential for success in the programme.
I agree that the above-named referees may be contacted for the purposes described above.
Signed:
Date:
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.
Signed
Date
10. ATTACHMENTS
Academic course records (essential, if not a graduate of The University of Auckland)
Curriculum vitae (optional)
Documents supporting any previous supervised or mentored practical experience, that meet the Behaviour
Analyst Certification Board© requirements. (Necessary if prior experience is being claimed).
Any other information that you believe may support your application. (Optional).