Current Status: Applications Open

Current Funding Round: Funding Round 5 application window closes 31 January 2020.

Important information before submitting an application (updated 25 September 2019)

  1. Before completing this application form, please carefully read the Application Guidelines to ensure your eligibility for the SRSA program.
  2. The total maximum grant amount you can apply for is $10,000. You may apply for more than one CPD activity, so long as the total does not exceed $10,000.
  3. CPD activities must be completed within Australia.
  4. The Assessment Panel prioritises clinical attachments, mentorships, peer review and workshops/courses over Annual Scientific Meetings and conferences.
  5. CPD activities must be completed between 1 April 2020 to 30 April 2021.
  6. Applications close on 31 January 2020.

Privacy Statement

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.

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1. Applicant details


Name must match AHPRA Register of practitioners database

Must be a Fellow of at least ONE Specialist Medical College











Residential address rural/remote rating must be MM2 or higher.

Practice address rural/remote rating must be MM2 or higher.
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.



E.g. 1.0 FTE = Full Time, 0.5 FTE = Part Time

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

CPD Activity 1

Description of activity
Learning and evaluation
Budget



4. DECLARATION