Application Form and Important Information for the Rowan Nicks Pacific Islands Scholarship 2015

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1 Application Form and Important Information for the Rowan Nicks Pacific Islands Scholarship 2015 Instructions Read the following information and make sure you meet the eligibility criteria Complete ALL boxes in the Application Form Complete the Application Form in English Attach a copy of your current Curriculum Vitae in accordance with the provided template Attach a certified copy of your basic medical degree and English translation Attach a certified copy of your post-graduate qualification and English translation Attach a certified copy of your current Medical Registration and English translation Attach a copy of either your IELTS, OET, NZREX or PLAB test results (see appendix 1) Attach a copy of the completed Application Checklist Send a signed, hard copy of this form and all attachments to: Secretariat, Rowan Nicks Committee Royal Australasian College of Surgeons College of Surgeons Gardens Spring Street East Melbourne, Victoria 3002 AUSTRALIA Applications must be submitted by no later than 5pm Australian Eastern Standard Time on Monday, 5 May 2014 i

2 About The Rowan Nicks Pacific Islands Scholarship The Royal Australasian College of Surgeons (the College) offers the Rowan Nicks Pacific Islands Scholarship each year. The Rowan Nicks Scholarships and Fellowships are the most prestigious of the College s international awards and are directed at qualified surgeons who have the potential to be leaders in their countries. The Rowan Nicks Pacific Islands Scholarship is specifically for surgeons from Pacific Islands in the South West Pacific Region. The Scholarship provides opportunities for surgeons who demonstrate the potential to become leaders in their country of origin, and/or to surgeons who will return to supply a much-needed service in a particular surgical discipline. The intention is to develop their skills to enable them to: Manage a department Become competent in the teaching of others Gain experience in clinical research and the applications of modern surgical technology, and; Obtain further advanced exposure in general or specialist surgery Whilst the foregoing is the ideal, the circumstances and specific needs of potential candidates and their countries could be somewhat different and this should not preclude such persons from applying for the Scholarship. Selection is primarily based on merit, however, applications providing a valuable service in remote areas, without opportunities for institutional support or educational facilities will be given special consideration. The Rowan Nicks Scholarships are not just personal awards; the orientation is to teach the teacher to teach others and the recipient must come with a sense of responsibility to the needs of his/her country. The intention is that the Scholar will share the skills and expertise with their colleagues upon return to their home country, thereby increasing the local capacity to deliver improved surgical and medical care to the local community. Applicants should demonstrate: A high calibre in surgical ability, ethical integrity, and qualities of leadership A commitment to teach and promulgate high standards in the development of surgery in their country Conditions of the Rowan Nicks Pacific Islands Scholarship The Scholarship is usually tenable in a major hospital (or hospitals) in Australia or New Zealand, and will be awarded for a period of up to 12 months. The Scholarship will provide funds for return economy class travelling expenses between the home country and hospital attachment for the Scholar as well as support to attend the Royal Australasian College of Surgeons Annual Scientific Congress (ASC) or equivalent conference (if in Australia or New Zealand at the relevant time). Funds to attend the ASC will be supplied to cover the cost of registration, travel and accommodation for the Scholar only. A living allowance equivalent to AUD$50,000 for 12 months in Australasia or appropriate pro-rata for another country will be provided to the Scholar in instalments. The value of the Scholarship may be reduced if the Scholar will receive a salary or funding from another source while undertaking the Scholarship program. Candidates are obligated to declare to the Committee any additional funding obtained or applied for at the time of application, after the submission of the application and at any stage during the selection process and during the tenure of the Scholarship. The Scholarship does not cover any costs associated with the Scholar s family members. Scholars are welcome to be accompanied by family members at their own cost. The Scholar will be encouraged to visit other appropriate institutions in Australia and New Zealand or appropriate other country during their attachment. Funds required for travel for this purpose will be considered on an individual basis. The Scholar must provide a progress report half-way through a 12-month Scholarship and also at the conclusion of the Scholarship. The final report should be no less than 1000 words in length. When the Scholarship is for 6-months or less, one report only will be required. ii

3 Eligibility for the Rowan Nicks Pacific Islands Scholarship Applications for the 2015 Pacific Islands Scholarship are open to qualified surgeons from*: Applicants must: Cook Islands Papua New Guinea Fiji Samoa Kiribati Solomon Islands Federated States of Micronesia Marshall Islands Nauru Tonga Tuvalu Vanuatu * Applicants from other countries outside the above list considering applying for the 2015 Scholarship must contact the Secretariat before the closing date to confirm whether they are eligible to apply. 1. Be a citizen of the country from which the application is made. 2. Be between the ages of years inclusive on the closing date of applications. 3. Have completed post-graduate training in surgery, and hold his/her country s post-graduate qualification in surgery, or have completed the Master of Medicine (MMed) examination. This is essential. 4. Be fluent in the English language. Applicants must provide evidence that they meet the English language requirement for registration with the Medical Board of Australia or Medical Council of New Zealand. See Appendix 1 for details of the minimum requirements. 5. Provide the names and full contact details of the referees and sponsor as outlined in the application form. Failure to include the names of referees may adversely affect the application in the selection process. 6. Guarantee to return to his/her home country on completion of the Scholarship. Referees and Sponsorship: Following the closing date for applications the College will contact the persons listed to obtain written references. Persons must not be listed more than once in a single application form. Please do not supply written references with your application form. The references the College will be seeking are in a standard format and additional references will not be considered. For each of these sponsors or referees the following guidelines must be met: Professional Referees - These are 2 referees such as surgical colleagues or supervisors who are able to comment on you in a professional capacity. To ensure that the College is able to collect a comprehensive reference from the referees, please include referees who are able to comment on areas of your performance such as your experience, reputation and surgical skills. It is compulsory that full contact details for 2 referees be supplied. Hospital or University Sponsor - It is compulsory that you supply the name and contact details of a sponsor from your Hospital or University. Such a person would include the Head of the Department, Hospital or University, or the Ministry of Health. A supervisor or colleague is NOT an appropriate sponsor. This person will be asked to comment on areas of your professional standing in your community, without necessarily being familiar with your surgical skills. The latter will have been addressed by your referees. Additional Referee - You may supply the name and contact details of an Australian or New Zealand referee with whom you have worked and who is able to comment on you in a professional capacity. It is NOT a compulsory requirement to have an Australian or New Zealand referee. iii

4 Selection Procedure for the Rowan Nicks Scholarship Applicants will only be considered if they meet the eligibility requirements of the Scholarship and have completed the Application Form in its entirety following the instructions supplied. Applications must be received by 5pm AEST on Monday, 5 May 2014 at the following address: Secretariat, Rowan Nicks Committee Royal Australasian College of Surgeons College of Surgeons Gardens Spring Street East Melbourne, Victoria 3002 Australia Telephone: Facsimile: international.scholarships@surgeons.org Applications received after this date will not be considered. The Rowan Nicks Committee will undertake the review and selection of the Scholars (see attached Mark Sheet, Appendix 2). The Committee will primarily consider the potential of the applicant to become a leader in the country of origin, and/or to supply a much-needed service in a particular surgical discipline. The Committee must be convinced that the applicant is of a high calibre in surgical ability, ethical integrity, and qualities of leadership, and the references collected by the College from the referees support the applicant as one who will teach and promulgate high standards in the development of surgical experience in their country. The Selection Committee will make the final recommendations to the College Council in October Once an official decision is made all applicants will be officially notified of the outcome via by 31 December The view of the Council will be final. iv

5 Application Form for Rowan Nicks Pacific Islands Scholarship Personal Details Title Family Name (as shown on Birth Certificate) Married Name (if different from name on Birth Certificate) Given Names (as shown on Birth Certificate) Country of Citizenship Gender Male Female Date of Birth (must be between years by closing date of applications. Proof of age may be requested) 2. Contact Details Current Residential Address Address Line 1 Address Line 2 Address Line 3 Town/City Postal Code (if any) State/Province Country Home Phone number Work Phone number Mobile number 1

6 Mailing Address (only if different from your current residential address): Address Line 1 Address Line 2 Address Line 3 Postal Code (if any) Town/City State/Province Country 3. English Language Proficiency Are you fluent in the English Language? Yes No Have you taken an IELTS (or equivalent) test? Yes No (Note: Applicants will be required to meet the English Language Requirement for medical registration in Australia or New Zealand) Date test taken: Test Results: Listening Test Reading Writing Speaking Overall Band Score Details of any English language training currently being undertaken 4. Conferences Attended 5. Papers Presented 2

7 6. Proposed Program Activity a. What program or course of study would you pursue using this Scholarship? ( words suggested) b. What are your specific skills and knowledge objectives for your proposed program or course of study? c. If you are offered the Scholarship, what is your preferred location for your placement? Australia New Zealand Other (Please Specify): d. For what length of time would you like to undertake this Scholarship? 3 months 6 months 9 months 12 months 7. Supporting Statements a. What is your motivation for applying for this Scholarship? ( words suggested) 3

8 b. If successful in obtaining this Scholarship, what contributions do you plan to make to improve health outcomes in your home country after completing your attachment? How do you plan to meet these objectives? ( words suggested). c. If successful in obtaining this Scholarship, how do you plan to share the skills and knowledge you gain in Australasia with your colleagues in your home country after completion of your attachment? ( words suggested). d. How would this experience improve your leadership potential? ( words suggested) e. Is there anything else you would like to add in support of your application for this Scholarship? 4

9 8. Referees and Sponsorship Please provide the names and full contact details of 2 referees who are able to comment on you in a professional capacity. Reference One Title Name Position Institution Address Line 1 Address Line 2 Town/City Postal Code (if any) State/Province Country Telephone Reference Two Title Name Position Institution Address Line 1 Address Line 2 Town/City Postal Code (if any) State/Province Country Telephone 5

10 Additional Referee (Optional) Please provide the details of an Australian or New Zealand Fellow with whom you have worked in a professional capacity. (Please note this is optional. It is NOT necessary to list an Australian or New Zealand reference). Title Name Position Institution Address Line 1 Address Line 2 Town/City Postal Code (if any) State/Province Country Telephone Hospital or University Sponsor Please provide the name and details of a Hospital or University referee such as the Head of the Hospital or University, Head of your Department or the Ministry of Health. This person should be a sponsor and NOT a referee. Title Name Position Institution Address Line 1 Address Line 2 Town/City Postal Code (if any) State/Province Country Telephone 6

11 Declaration I confirm that the information supplied within at the time of application is correct, and acknowledge that I am obligated to advise the Rowan Nicks Committee of the Royal Australasian College of Surgeons (the College) of any changes to the information supplied within this application at any stage during the application period, selection process or while undertaking the Scholarship (if successful). I have read the Conditions of the Rowan Nicks Scholarship of the College and agree to abide by these conditions. I acknowledge that I am obligated to declare any additional funding obtained or applied for at the time of application, after the submission of the application and at any stage during the selection process and after the commencement of the Scholarship (if successful). I note that the amount of the Scholarship awarded will be at the discretion of the Committee and may be reduced if I accept a salary or payment from my host institution or if I am successful in raising additional funds at any stage before or after the commencement of the Scholarship. I consent to the information on this form being used and disclosed as stated. Signature Date This application form, completed in its entirety, must reach the Rowan Nicks Committee Secretariat via post, fax or by Monday 5 May

12 Rowan Nicks Pacific Islands Scholarship Application Checklist The below is required for your application. Please make sure you have attached all required documents in their correct form to this application. Please do not send any other documents unless requested. Certified copy of basic qualification English translation must be attached Certified copy of post-graduate qualification English translation must be attached Certified copy of current Medical Registration English translation must be attached Copy of either your IELTS, OET, NZREX or PLAB test results (see appendix 1) Full contact details of 2 professional referees Full contact details of 1 sponsor from your Hospital or University Full contact details of sponsor in Australia or New Zealand (optional) Current CV formatted in accordance with the provided template 8

13 Appendix 1 English Language Requirement Applicants for the Rowan Nicks Pacific Islands Scholarship must provide evidence that they meet the English language requirement for registration with the Medical Board of Australia or Medical Council of New Zealand in order to be eligible for a 2015 Rowan Nicks Scholarship. The following tests of English language skills are accepted by the Boards for the purpose of meeting the requirement. For registration in Australia: a) b) c) d) The IELTS examination (academic module); The OET examination; NZREX; PLAB test Current as of July 2010, all applicants to the Medical Board of Australia MUST be able to demonstrate English language skills at IELTS (academic module) level 7 or the equivalent. Please refer to the Medical Board of Australia: English Language Skills Registration Standard for more information about the minimum requirements: For registration in New Zealand: a) The IELTS examination (academic module); b) NZREX; Current as of October 2010, all applicants to the Medical Council of New Zealand MUST be able to demonstrate English language skills at IELTS (academic module) level 7.5 for speaking and listening, and level 7 for writing and reading or the equivalent. Please refer to the Medical Council of New Zealand: Policy on English Language Requirements for more information about the minimum requirements: Notes: Results from any of the abovementioned English language examinations must be obtained in one sitting. Please refer to the IELTS website for further information and local test dates in your country: The examination fee is to be borne by the applicant. If you are unsure whether you meet the English Language eligibility criteria please contact the Secretariat prior to the closing date for further information. 9

14 Appendix 2 ROYAL AUSTRALASIAN COLLEGE OF SURGEONS ROWAN NICKS SCHOLARSHIP 2015 MARK SHEET To be completed by members of the Rowan Nicks Committee Candidate: Marker: Total Mark (out of 45): (sum of parts 2 and 3) 1 Eligibility (Secretariat to Complete) 1. Appropriately Qualified - the applicant has completed relevant post graduate training in Surgery Yes / No 2. Sponsorship - from Head of Department / Ministry of Health confirming support of the Program Yes / No 3. References received, positively describing the applicant's surgical competence, ability and character Yes / No 4. English Language - Meets English Language requirement for Medical Registration in Australia or New Zealand. Yes / No 2 The Application 1. Experience in surgical discipline. /10 2. Academic attainment in addition to stipulated higher degree, eg: PhD, substantial number of papers presented etc. /5 3. Definition of objectives to promote surgery in home country. /5 4. Demonstration of leadership potential / contribution to the wider community. /10 3 Appropriateness of Candidate 1. Appropriateness of proposed program to the needs of the home country / Value of proposed program to home country. /5 2. Match of the candidate to the objectives of the program & Deliverability of the proposed program (ie. has the candidate got the capacity to succeed). /5 3. OVERALL appropriateness including impression of applicant's ability to become a leader. Weigh up the balance of qualifications, training experience and referee reports in light of the following identifiable criteria: Age of candidate in relation to opportunities Previous opportunities already enjoyed (e.g. travel, courses etc.) / Conversely, lack of opportunities because of impoverished state of the country, geographic site of practice, political and professional pressures Status and leadership positions already achieved determining placement and experience. A realistic assessment by the candidate of the priority surgical needs of the country The vision, enthusiasm and suitability of the candidate to meet those needs. Reference from an Australasian Fellow who knows and has worked with the applicant. Rowan Nicks International and Pacific Islands Scholarship Mark Sheet /5 10

15 Curriculum Vitae Template Personal Information Name: Address: Phone: Qualifications Obtained Qualification- YYYY Name of Institution Qualification- YYYY Name of Institution Bridging Programs / Qualifying Examinations (Internship) Position Title From: DD/MM/YYYY to DD/MM/YYYY Name of Facility Address: Result: Clinical / Procedural Skills -Competent (or observed) [describe skill] -Competent (or observed) [describe skill] -Competent (or observed) [describe skill] Work / Practice History Position Title From: DD/MM/YYYY to DD/MM/YYYY Name of Facility Address: Telephone: Responsibilities: List responsibilities Full time or part time (hours worked per week) Position Title From: DD/MM/YYYY to DD/MM/YYYY Name of Facility Address: Telephone: Responsibilities: List responsibilities Full time or part time (hours worked per week) This Curriculum Vitae is true and correct as at (Date) (Signed) 11

16 Internship and Observership Position Title From: DD/MM/YYYY to DD/MM/YYYY Name of Facility Address: Result: Gaps in Work / Practice History There are no gaps in my practicing history except for recreational purposes or transfer of leave. Please explain any gaps that exceed 3 months in duration. Registration History Current Registration Details From: YYYY to YYYY Registration Number: Previous Registration Details From: YYYY to YYYY Registration Number: I have not been previously registered to or am awaiting consideration from any other jurisdictions. References and Publications If applicable This Curriculum Vitae is true and correct as at (Date) (Signed) 12