1. Before completing this application form, please read the Individual Application Guidelines.
  2. Where the applicant is not affiliated with a College (i.e. area of need practitioner, staff specialist), the applicant is also required to submit a letter from the employer confirming their status as a specialist.
  3. Applications will be considered on a case by case basis with priority given to more remote applications, using the Modified Monash Model (MMM) geographical classification system.
  4. The applicant must have been living and working in the rural and remote area for no less than 12 months.
  5. Backfill for individual funding support may also be considered where, without such support a medical specialist may not be otherwise able to participate in approved CPD activities.
  6. Annual Scientific Meetings are considered lower priority than practical skills workshops or courses.
  7. The total maximum grant amount an applicant can apply for is $10,000 for a maximum of five days, at a maximum rate of $2,000 per day (i.e. workshop registration, travel costs and accommodation).
  8. Please supply a URL or flyer providing more information on the nominated CPD event.
  9. The proposed CPD event must take place in Australia, between the 1 November 2018 and 31 December 2019. No retrospective funding will be considered.
  10. If the applicant registers for a CPD event before being informed of the outcomes of the Assessment Panel, they do so at their own risk. Please ensure you keep your receipts so that if your application is successful you can be reimbursed.
  11. Applications will be assessed by an Assessment Panel, appointed by the SRSA Sub-Committee.
  12. Applications will be assessed according to the Eligibility and Selection Criteria outlined in the Individual Application Guidelines.
  13. Post assessment feedback will be provided to both successful and unsuccessful applications.
  14. Successful applicants must provide all relevant original receipts for full reimbursement.
  15. Statutory Declarations will not be considered.
  16. If you require further information on the application process please contact the SRSA PMU at admin@ruralspecialist.org.au or 02 9256 5419.

The information provided by you in this application form will be used to assess your eligibility to receive funding under the Support for Rural Specialists (SRSA) Program and for reporting and research purposes. Any information you have supplied in connection with your application will be dealt with in accordance with the National Privacy Principles of the Privacy Act 1988.

SRSA Funding Round 3 – Individual CPD Grant Application Form

Applications close: 5pm AEST 31 August 2018

Proposed CPD activities must occur between: 1 November 2018 and 31 December 2019

1. Applicant details


Must be a Fellow of at least ONE Specialist Medical College

Location must be classified between MM2 and MM7 (as per the Modified Monash Model)

Residential AddressPractice Address


Total time practising in rural/remote locations must be at least 12 months

2. Needs Assessment


YesNo
Please list the last 3 CPD activities you have participated in, including date and location (i.e. local activities such as audit or formal CPD activities)


3. Proposed CPD activities

4. Summary

The table below is a summary of the CPD activities you are requesting SRSA funding support for. Grant applicants may apply for $2,000 per training day, up to a maximum of 5 days (i.e. $10,000). Please ensure all the information is correct and within the Budget Guidelines.

# Activity Name Location Dates Budget
Total funding requested $

If your CPD activity is not listed above, please ensure all fields are completed in the section 3. Proposed CPD activities form.

5. DECLARATION

I declare that:
The information in Section 1 is true and correct.
The information in Section 2 – 3 provides an accurate reflection of my current CPD and peer support needs.
The information above outlines a CPD activities which will support my capacity to practice as a specialist in a remote area.
The CPD proposal outlined above will be implemented as per the information above, and any variations will be discussed with the SRSA Program Management Unit.
I understand that I am required to complete an evaluation of my involvement with this SRSA funding support.
I consent to my submitted data being collected and stored.
Full Name:
Date:

Applications are to be submitted by the closing date: 5pm AEST 31 August 2018.

If you have any questions or concerns regarding your CPD grant application, email: admin@ruralspecialist.org.au