Application for Clinical Leadership Funding 2016
This form is to be completed by students accessing the Te Pou Clinical Leadership funding stream at The
University of Auckland, School of Nursing. Applicants will be employed in publicly funded mental health
and addiction services. Please complete and forward to Lee-Anne Govender, Postgraduate Manager,
School of Nursing, University of Auckland, Private Bag 92019, Auckland 1142. This information will be
provided in confidence to Te Pou and the University Fees Office.
Please note: Applications completed without necessary documentation and information will not be
considered.
SECTION ONE (To be completed by the student )
Surname:
_______________________________Forenames:________________________________________
Home Address
________________________________________________________ ___________________________
Telephone (Work):______________________________Mobile: ___________________________________________
Email:
_________________________________________________________________________________
Date of Birth:__________/__________/____________Gender:__________________________________________________
Primary Ethnicity
Secondary Ethnicity
IWI
SECTION TWO (To be completed by the student)
Programme
Student ID No.
Tick one
√
Postgraduate Certificate
Postgraduate Diploma
Master of Nursing
Semester
ONE
Course Title
Course Code
Semester
TWO
Course Title
Course Code
Hours worked per
week/FTE
Please Tick √
Service Type
Child & Youth
1.0 FTE/40+ hours
Adult
Please
Tick √
0.9 FTE/36 hours
Older Persons
0.8 FTE/32 hours
Maori
0.7 FTE/28 hours
Pacific
0.6 FTE/24 hours
Asian, Refugee or
Migrant
Nursing Council
Registration No.
Forensic
Other
SECTION THREE (To be completed by Associate Director of Nursing (Mental Health) of the agency employing the student)
Name and Title:_______________________________________________________________________________________
Clinical Agency: _________________________________________________________________ DHB/NGO/Other (Circle)
Postal Address: ________________________________________
Telephone: __________________________________
_______________________________________
Fax:______________________________________
______________________________________
Email:
Supervisor’s name:______________________________________
____________________________________
Email:_______________________________________
EMPLOYER SUPPORT STATEMENT
Te Pou requires the student’s Associate Director of Nursing (Mental Health) (or equivalent for non-DHB
employees) to support the student taking the courses/programme listed on the next page.
I confirm that the above student is eligible for other funded status for the above courses, including tuition
fees, materials and resource fees, building levy and student services fee and ROPAS fee for recognition of
overseas qualification, where applicable.
I confirm that this organisation will provide support to access professional supervision, and will provide
release time as described in the letter of agreement with the school for the applicant to attend the theoretical
component of the programme / courses.
SIGNED: _____________________________________________DATE:___________________
This form must be accompanied by:
√
A career plan, signed by your Associate Director of Nursing (Mental Health) (or equivalent clinical leader / manager
for non-DHB employees) .
Your supervision contract for 10 hours professional supervision during the academic year (or a pro rata number of
hours if you are enrolled in less than 60 points of study). Please note that Te Pou funded professional supervision is
separate to any clinical supervision you are receiving, and separate to academic supervision provided by academic
staff of the University.