Please type information into form as far as possible and then print out for signatures.

In order to plan for your Professional Experience Placement (PEP) the School of Nursing & Midwifery requires details of your proposed placement(s) and venue(s).

1. Your DetailsPlease provide your full names rather than initials

Flinders Student ID:(if applicable)

Title:(Mr, Mrs, Ms, Dr)

Family Name: Given Name(s):

Home Telephone Number:(include area code) ( ) Mobile Number:

Email Address:

Mailing Address:

2. Your Program of StudyI have been admitted into:☐ Graduate Certificate in Primary Health Care (General Practice and Community Nursing)☐ Graduate Diploma in Nursing (General Practice and Community Nursing)☐ Master of Nursing (General Practice and Community)

Please see relevant Study Plans to assist with topic selection.

3. Professional Experience Placement (PEP) requirements

As a postgraduate student studying General Practice and Community Nursing, you must undertake a 5 day clinical placement. You are required to negotiate your own placement in an appropriate General Practice or Community nursing environment. If you are employed in such an environment you may negotiate a Work Integrated Learning placement with the Topic Coordinator.

4. Employer/Clinical Venue SupportYou are required to show evidence that your Clinical Manager or proposed host venue manager will support your completion of the PEP components of the course. It is essential that this section be signed by your employer or host venue/clinical manager before you submit this form.

To be completed by your Clinical Manager/host venue manager:As Clinical Manager/host venue manager, please complete the section below as evidence that your venue will support the completion of the clinical practice components of the course for this applicant.

PEP Support Form: General Practice and Community Nursing: NURS8722 (Version 3.0) Page 1 of 3

School of Nursing & MidwiferyProfessional Experience Placement (PEP) Support Form:

General Practice and Community NursingNURS8722 Clinical Care in Community Nursing (PEP) – Semester 2

Please provide full names rather than initials. Clinical Manager’s Name & Title:

Clinical Manager’s Role:

Clinical Manager’s Phone Number:(include area code) ( ) Clinical Manager

Email:

Ward/Region/Team of Employment:

Organisation’s Name in full:

Is student employed at this venue? ☐ Yes ☐ No

Organisation’s Street Address:

Organisation’s Mailing Address:(if different to above)

ABN (Private organisation only):

Proposed placement dates:

I agree that the required support will be provided to the applicant to undertake the professional experience placement components of the course within this workplace (please tick):

☐ Provide 5 days of clinical placement in a general practice or community nursing environment☐ Allocate or assist with the choice of preceptor(s) in the clinical area ☐ Supervision in and assistance with acquisition of clinical skills ☐ Provide guaranteed support for the entirety of the agreed placement duration

Clinical Manager’s Signature:(or equivalent)

Date:

Director of Nursing or Designated Proxy: Date:

5. Preceptor DetailsThe School requires the details of at least one preceptor who will support your placement(s) for every venue.

Preceptor 1 – please provide full name rather than initials

Name and Title:

Position and Role Title:

Service / Department:

Organisation in full:

Qualifications:

Telephone:(include area code) ( ) Mobile:

Email:

Preceptor 2 - please provide full name rather than initials

Name and Title:

Position and Role Title:

Service / Department:

Organisation in full:

PEP Support Form: General Practice and Community Nursing: NURS8722 (Version 3.0) Page 2 of 3

Qualifications:

Telephone:(include area code) ( ) Mobile:

Email:

In addition to your preceptor, the School of Nursing and Midwifery will provide a PEP facilitator who will contact you within the first two weeks of your placement. The PEP facilitator will link the topic’s theory and practice from a university perspective and will support both you and your preceptor(s).

6. Important Additional RequirementsIt is essential that the following arrangements are in place before you commence your placement even if the placement is within your own workplace:

1. An Affiliation Agreement between your host venue and the University must be in place before you can commence your placement even if your host venue is also your employer. If an agreement is not in place it can take up to eight weeks for this legal process to be completed. The University undertakes this process for you and we ask that you submit this form as soon as possible to ensure that we can conduct these negotiations before you are due to commence your placement(s). The University will advise you if you need to delay your placement whilst an Affiliation Agreement is negotiated and advise you when you are able to commence your placement once it is in place.

2. The Professional Experience Placement Unit must receive evidence that you comply with all the Pre-placement Requirements as outlined on the Student Responsibilities page of the Postgraduate PEP website before a placement can be undertaken. Please refer to: http://www.flinders.edu.au/nursing/professional-experience-placements/postgraduate/pg-resp/pg-resp_home.cfm.

7. Applicant’s Declaration I agree that the School of Nursing & Midwifery may contact the venues/host venue I have detailed here, if there are questions

regarding the placements I have nominated. I consent to the School of Nursing & Midwifery providing my nominated preceptors with my contact details prior to the

commencement of my placement. I acknowledge that if I fail to provide all required documentation in a timely manner prior to my placement I may be required to

withdraw from the topic. If this occurs beyond the census date for the topic(s), then penalties (including financial costs for the topic) will be incurred by me.

If I decide to withdraw from my topic enrolment(s), I will do so via the Student Information System prior to the census date for the topic(s).

I have read and understood Section 6. Important Additional Requirements and accept the School of Nursing & Midwifery’s pre-placement requirements.

Applicant’s Signature: Date:

8. Submitting This Form

Scan and email the completed form to clinical.placements@flinders.edu.au. A return email will confirm satisfactory receipt of your documentation.

It is recommended that you retain a copy of the completed document for your records.

PEP Support Form: General Practice and Community Nursing: NURS8722 (Version 3.0) Page 3 of 3