HWNZ funding application form
Post Graduate Education Funding (HWNZ Funding)
Application Form for Registered Nurses employed with
the Counties Manukau Health funding area
Name: _______________________________________
Last day for applications is:
CMDHB employees –see back page 20th March 2015.
Non- CMDHB staff- see back page by 17th April 2015.
The outcome of the application will be made known to you, in writing to your work address (unless otherwise
notified), No later than 12th June 2015.
All applicants must have completed a career plan with their line manager before applying for HWNZ
funding. Please see either Southnet Career Development site
Or
http://www.healthworkforce.govt.nz/health-careers/career-planning
PLEASE NOTE: YOU WILL NEED TO APPLY FOR FUNDING EVERY SEMESTER. IF YOUR APPLICATION IS SUCCESSFUL IT IS ONLY FOR
ONE SEMESTER AT A TIME.
All sections must be completed. All incomplete applications will be returned for completion
Criteria:
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Be a registered nurse and hold a current new Zealand Nursing Council’s Annual Practising Certificate
Be employed in a permanent (part or full time) nursing position in a health service that is funded by Counties Manukau
Health or the Ministry of Health from Vote Health monies
Be a New Zealand Resident or Citizen
Be compliant with the organisations Professional Development and Recognition Programme (PDRP) [if has one]
If commencing postgraduate diploma or Masters then must be proficient , expert or senior level on the PDRP
Career plan completed
Priority given to high workforce development needs as identified by MOH and CM Health strategic and workforce
development documents
Preference given to applicants completing their qualification
Papers must be level 8 and be able to be credited towards a Masters of Nursing programme approved by the New Zealand
Nursing Council
Form completed in full and within time frames including signatures by applicant and line manager
Please note: To ensure all applications are given an equal opportunity to secure HWNZ funding to undertake post graduate
education, ALL the following information must be supplied. This is a requirement by Health Workforce New Zealand (HWNZ),
Ministry of Health and will only be released to HWNZ for reporting and auditing purposes and to meet the requirements of the
Privacy Act 1993.
NOTE: If planning to undertake a prescribing practicum in semester 1 or 2 then the Post Registration/PDRP
Lead must be notified in the end of year Funding round and section 8 must be completed.
Developed by Nurse Coordinator, Post Graduate Education. March 2007, updated 2015.
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HWNZ funding application form
Surname:
1. Personal Details
First Name:
Date of Birth:
Male
Female
Work position:
Work Area (Name of Ward, Unit, Medical Centre etc):
Note: both line managers will
need to support application
Note: need postal
addresses to send any
letters out- usually sent to
work address unless
indicated
If a Primary Healthcare Organisation please circle one:
Alliance Health Plus
East Health Trust
Total Healthcare
National Hauora Coalition
Procare Networks Ltd
Do you work in more than 1 area:
Yes
No
If yes: second work area:
Work Postal Address:
Home Postal Address:
Phone- work :
Note: Email will be the main
form of contact. Please
print clearly.
Home:
Cell phone:
Email:
Years employed at organisation:
Full time equivalent (FTE) status: (hours worked per fortnight):
2. NZ Nursing Council
Note: Must be a Registered
Nurse &
Please ensure name is as
per NCNZ website
Please send non-verified
copy of APC if first time
applicant
Is the name that appears on your Nursing Council of New Zealand’s Annual Practicing
Certificate the same as above
Yes
No
If No: Name on APC:
Reason for difference:
Annual Practising Certificate Number:
Scope:
Expiry Date:
Are there any “Restrictions to Practice” on your APC:
Yes
No
If yes-what is it?
3. New Zealand
Residency Status
NZ Born
Note: If not a NZ citizen or
resident-sorry unable to
fund
NZ resident/citizen
Yes
No
If No, please complete below :
Yes
No
_____________If YES: MUST include non-verified copy of certificate of citizenship/residency
visa (first time applications only)
4. Ethnicity:
Please circle one:
NZ European /Pakeha
European
Southeast Asian
Asian nfd
Indian
Middle Eastern
Latin American/Hispanic
African or cultural group of African Origin
Other Ethnicity ……………
Pacific Islander (please specify): …………………
NZ Maori
Iwi …………………………….. Hapu………………………
Note: Maaori and Pacific funding is available to provide you with mentoring and cultural supervision.
It can also be used for cultural development resources (up to a maximum of $200). A formal
mentoring plan must be completed as part of this. Please contact The Nurse Coordinator PGE for
Developed by Nurse Coordinator, Post Graduate Education. March 2007, updated 2015.
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HWNZ funding application form
further details.
If Maaori or Pacific- would you like additional funding for mentoring and/or cultural
supervision (see note)?
5. Professional
Development and
Recognition
Programme
YES
NO
NB. If your organisation has a portfolio process, then you MUST be compliant to receive
HWNZ funding. It Will be checked.
Full Portfolio due date:
PDRP Level: please see note then circle one
Competent
Proficient
Expert
Senior
Note: must be proficient or higher to commence a Post Graduate Diploma (if organisation has PDRP)
6. Educational Record
Year last enrolled in Tertiary education:
Current highest qualification level:
Have you received any educational funding before:
Yes
No
Is yes, from where?
HWNZ
Yes
No
Year: _________
NETP
Yes
No
Year: _________
PG Paper completed Semester
Note: if undertaking
PGDiploma must be
Proficient level or higher.
If commencing Mastersdiscussion must be held
with CND/Nurse Leader, &
CNM/CMM/TL & NE and/or
Post Registration/PDRP
Lead
or
2
Director of Nursing (Accrued) Funds
Yes
No
Year: _________
Te Pou
Yes
No
Year: _________
Other: please specify:
7. Education Planned
1
Year: _________
What programme enrolled in or planned (must circle one):
BN Honours
Post Graduate Certificate
Post Graduate Diploma
Masters
University/ Technical Institute: ___________________________
Student ID (if Known) ____________________________
Date (Month/year) started qualification ______________________________
Date (Month/year) expected to complete qualification _____________________
Is this your first paper of your qualification?
Yes
No
At what campus will you be studying at? ____________________________________
Do you need Travel and accommodation subsidy? Travel and Accommodation is only available
if you need to travel more than 100kms from place of work one way (excluding Wintec in Hamilton
for CMHealth staff)
Semester 1
Yes
No
Semester 2
Yes
No
Papers completed and planned to complete qualification: please clearly identify S2, 14
paper.
NOTE: if planning to undertake a nurse prescribing practicum-you MUST contact the Post
Registration/PDRP Lead before completing this application form- all applications for prescribing
practicum must be completed in the August application round for the both semesters- see section
8.
Developed by Nurse Coordinator, Post Graduate Education. March 2007, updated 2015.
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HWNZ funding application form
Semester,
year
Paper
number
Paper Name
Single or Points
double
semester
Note: all applicants must complete a career plan as part of the performance review/
appraisal process. Note: This section developed after discussion with Nurse Educator
/Charge Nurse Manager (only if no Nurse Educator available) / Clinical Nurse Director / Post
Registration/ PDRP Lead.
I agree that the academic plan is appropriate for the applicant to assist them meet their
career goals as per their career plan, service and organisational needs. I have considered
any pre-requisites and requirements for the paper.
Name:
Signature:
8. ONLY to be
completed if
undertaking a
prescribing practicum
in 2015.
Must be discussed
with your CND/ Nurse
Leader
Note: it is the expectation
of CM Health that if the
supervisor is an employee
of CM Health then the
supervision will be
undertaken within work
time and therefore require
no additional funding
Date:
ONLY to be completed if undertaking a prescribing practicum in 2015
Please outline your proposed arrangements for the Prescribing Practicum ONLY:
Clinical Access hours required :
Clinical Supervisor:
Costings of supervision:
Any other costs:
Developed by Nurse Coordinator, Post Graduate Education. March 2007, updated 2015.
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HWNZ funding application form
Number of days education leave required:
9. Rostering
requirements
Note. 15 points paper: 3-4 study days. 30 point paper: 6-8 study days. (Applicable for online papers
also, note if the education days fall on your normal rostered day off, then you might not get paid
education leave).
10. Line Manager
Agreement
Note: all applicants must
have completed a career
plan as part of their
performance development
review.
Note: if work in 2 areas,
both line managers must
support the application.
11. Applicant
Agreement
I have reviewed and discussed the above with the applicant.
 In signing this form I fully support and endorse this application for funding.
 I have also considered the rostering implications and the needs of the clinical area
and I am aware and will support the number of study days involved.
 I have seen and discussed the career plan of the applicant as part of the
performance review/ appraisal process
 I have discussed with the applicant how he/she will apply new knowledge and skills
back into the clinical area
Name:
Signature:
Position:
Date:
By signing this application I agree that:
 I have completed a career plan as part of my performance review process
 I will enrol into the university within the university timeframes.
 I will contact the Nurse Coordinator - PGE of ANY changes in my enrolment in
writing.
 Failure to successfully complete the Post Graduate Qualification I have indicated
(for reasons other than those beyond fair and reasonable causes) may result in CM
Health retrieving the monies back (see Policy)
 CM Health can seek confirmation of course completion and result from the
university/technical institute involved
 CM Health can release my details to HWNZ as per the Privacy Information Act
(1993)
 My name may be provided to other students so they can contact me to discuss the
papers I have completed or are currently undertaking.
 I understand that if I do not meet the criteria stated above, I may not receive any
funding
 I agree that if I am unsuccessful in my application, then my name can be placed on a
wait list.
Name:
Date:
Signature:
For further information contact:
Dianne Barnhill
Post Registration/PDRP Lead
Phone: 09-2760044 ext 8691
Fax: 09-2595077 (internal: 5077)
Mobile: 021 221 4816 (internal *3569)
Room 312, level 3, Support Building
Middlemore Hospital
Private Bag 93311
Otahuhu.1640
Email: dianneb@middlemore.co.nz
If CM Health staff- send application form to your Line Manager
(CNM, TL etc) or if a senior nurse to your CND.
If Primary Health Care Nurses send to:
Karyn Sangster Nurse Leader Primary Health care
Building 3/19 Lambie Drive,
Private Bag 94052, South Auckland Mail centre, Manukau 2240.
All Others send to:
Contracts & Placements Officer , NPDU, 3rd Floor, Support Building
Middlemore Hospital
Private Bag 93311,Otahuhu, Auckland 1640
Developed by Nurse Coordinator, Post Graduate Education. March 2007, updated 2015.
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