<p> College of Nursing and Health Sciences Professional Experience Placement (PEP) Support Form: </p><p>Cardiac Care  Critical Care  Emergency  High Dependency  Paediatrics </p><p> Please type information into form as far as possible and then print out for signatures. </p><p>In order to plan for your Professional Experience Placement (PEP) the College of Nursing and \ Health Sciences requires details of your proposed placement(s) and venue (your employer). Please note: you cannot be made an offer into the course until this form is completed and submitted to the University.</p><p>1. Your Details Please provide your full names rather than initials </p><p>Flinders Student ID: Title: (if applicable) (Mr, Mrs, Ms, Dr) Family Name: Given Name(s): Home Telephone Number: Mobile Number: (include area code) ( )</p><p>Email Address:</p><p>2. Your Program of Study</p><p>I am applying for (please tick) ☐Graduate Certificate or ☐Graduate Diploma or ☐ Masters in the following specialisation:</p><p>☐ CARDIAC 1. NURS8741 Professional Experience in Resuscitation Across the Lifespan (offered in Semester One & Two) - 24 x 8 hour shifts (192 hours) 2. NURS8745 Acute Cardiovascular Care (PEP) (offered in Semester 2) - 10 x 8 hour shifts (80 hours)</p><p>☐ CRITICAL CARE 1. NURS8741 Professional Experience in Resuscitation Across the Lifespan (PEP) (offered in Semester One & Two) - 24 x 8 hour shifts (192 hours) 2. NURS8743 Critical Care Nursing Practice (PEP) (offered in Semester 2) – 24 x 8 hour shifts (192 hours)</p><p>☐ EMERGENCY 1. NURS8750 Emergency Nursing Practice 1 (PEP) (offered Semester 1) – 24 x 8 hour shifts (192 hours) 2. NURS8752 Emergency Nursing Practice 2 (PEP) (offered Semester 2) – 24 x 8 hour shifts (192 hours)</p><p>☐ HIGH DEPENDENCY NURS8741 Professional Experience in Resuscitation Across the Lifespan (PEP) (offered in Semester One & Two) – 24 x 8 hour shifts (192 hours)</p><p>☐ PAEDIATRICS NURS8829 Paediatric Nursing Practice (PEP) (offered in Semester Two) – 225 hour clinical placement undertaken three days per week for ten weeks.</p><p>Please see relevant Study Plans to assist with topic selection. You must be employed in the clinical specialist setting in which you are applying to study as this placement must be undertaken as a Work Integrated Learning (WIL) model with your current employer.</p><p>3. Employer/Clinical Venue Support You are required to show evidence that your current employer will support your completion of the clinical practice components of the course. Please note that it is essential that this section be signed by your employer or host venue/clinical manager before you submit this form.</p><p>To be completed by your Clinical Manager/host venue manager:</p><p>PEP Support Form: Cardiac Care, Critical Care, Emergency, High Dependency, Paediatrics (Version 4.0) Page 1 of 3 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.</p><p>Please provide full names rather than initials. Clinical Manager’s Name & Title: </p><p>Clinical Manager’s Role: Clinical Manager’s Phone Number: Clinical Manager ( ) (include area code) Email: Ward/Region/Team of Employment: </p><p>Organisation’s Name in full: </p><p>Is student employed at this venue? ☐ Yes ☐ No</p><p>Organisation’s Street Address: Organisation’s Mailing Address: (if different to above) ABN (Private organisation only):</p><p>Proposed placement dates:</p><p>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): </p><p>☐ Provide the required number of placement hours in the designated 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</p><p>Clinical Manager’s Signature: Date: (or equivalent) Director of Nursing or Date: Designated Proxy:</p><p>4. Important Additional Requirements required after entry to the program It is essential that the following arrangements are in place before you commence your placement even if the placement is within your own workplace:</p><p>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. </p><p>5. Applicant’s Declaration</p><p> I agree that the College of Nursing and Health Sciences may contact the venues/host venue I have detailed here, if there are questions regarding the placements I have nominated.  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 4. Important Additional Requirements and accept the College of Nursing and Health Sciences’ pre-placement requirements.</p><p>PEP Support Form: Cardiac Care, Critical Care, Emergency, High Dependency, Paediatrics (Version 4.0) Page 2 of 3 Applicant’s Signature: Date:</p><p>6. Submitting This Form</p><p>Scan and email the completed form to [email protected]. It is recommended that you retain a copy of the completed document for your records.</p><p>PEP Support Form: Cardiac Care, Critical Care, Emergency, High Dependency, Paediatrics (Version 4.0) Page 3 of 3</p>