THE JOANNA BRIGGS INSTITUTE

THEU,NIVERSIITY

of ADELAIDE

Application Form

201: 1 Evidence-based Practice CUln,ical Fellowship Program

Application for Entry to the 2011 Evidence-basedP,ractice Clinical Fellowship Program.

Please ensure that the application form is completed and supporting documentation attached.

Application form complete?

Employer/Supervisor fonn complete?

Application Submission;

Submit the application either by mail, or fax or email:

Postal Address:

The Joanna Briggs Institute

81h Ffoorr=mergency Block Royal Adelaide Hospital North Terrace ADELAIDE SA 5000 Australia

Fax Number: +61 883034881

Email: jbieducation@adelaide.edu.au

JBI Evidence-based Practice Clinical Fellowship Program

Applicant's details

Name:
Address:
I
Contact: AlHPhone:
Mobile:
,
E·mail:
Work: Position:
CDm,pany Name: ,
Company Add,es9:
Business Phone:
Business Fax: 2

JBI Evidence-based Practice Clinical Fellowship Program

Qualifications:
YttlJr Study Institution Employment: Outline your employment history. Begin with your current position.
Poslt/onITltle Organis.allon Date'


I 3

JBII Evidence-based Practioe ClinicaliFeliowship Program

Professional experience! Interest

Briefly describe why you are interested in the Clinical Fellowship Progr.amand how your participation in the 'program would contribute to improving' healthcare,

Additional !BI.ographical Inforimatlion:

This space aUows for the addition of any relevant information the I applicant wishes the selection panel to see includi,ngl awards, ' prizes, training,. skills, experience, lectures etc.

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JBI Evidence-based Practice Clinical Fellowship Program

Evidence-based Practice Clinical Fellowship Program

REFEREE REPORT FORM

Referees: Please comment on the: applicant's work in healthcare, and their ability to partioipate in the program .. The references are to be sent directly to:

The Joanna Briggs Institute 8th Floor

Emergency Block

Royal Adelaide Hospital North Terrace ADELAIDE SA 5000 Australia

Fax: +61 883034881

Referee 1

Name:
Address:
Contact: AlHPhone:
Mobile:
E-mail:
Work: Position:
Company Name:
Company
Address:
BusIness Phone:
Business Fax: 5

JBI Evidence-based Practice Clinical Fellowship Program

How long have you known the applicant and in what capacity?

Comments related to the applicant's experience. skills and motivation In healthcare.

comments on the applicant's ability to complete the program.

Comments on the applicant's leadership potentlaJ.

Signature:

Date:

6

J81 Evidence-based Practice Clinical Fellowship Program

Evidene&based Practice Clinical Fellowship Program

REFEREE REPORT FORM

Referees: Please comment on the applicant's work in heal1hcare, and their ability to participate in the program. The ref,er'ences are to be sent directly to:

The Joanna Briggs Institut'e atnFloor

Emergency Block

Royal Adelaide Hospital North Terrace ADELAIDE SA 5000 Australia

Fax: +61 e 8303 4881

Referee 2

Name:
Address:
Contac:t: AlHPhone:
Mobile:
E-mail: ,
I
Work: Position:
Company Name:
Company
Address:
I ,Business Phone:
Business Fax: ! 7

JBI Evidenoe-based Practice Clinical Fellowship Program

How long have you Iknown the applicant and In what capacity?
Comments rellated to the ,ap,plicant's experience, skills and motivation In
healthcare.
I Comments on the applicant's ability to ,complete the program.
Comments on the applicant's leadership potential. Signature:

Date:

8

JBI Evidence-based Practice Clinical Fellowship Program

Evidence-based Practice Clinical Fellowship Program

EMPLOVER's/sUPERVISOR'S VERIFICATION FORM

I certify that, should be awarded an

Evidence Based Practice Clinical Fellowship, _______________ (name of health servicelagencylfaciHty) will:

• Provide paid leave: for a total of ten (10) days, plus travel time, for training of the applicant In Adelaide;

• Provide a minimum of three hours per week for the applicant to conduct their project for 20 weeks; and

• Provide support for Fellows in the workplace both during and at the conclusion of the program to allow the Fellow to share and implement knowledge gained during the Fellowship period.

Name:
Address:
Contact: AlHPhone:
Mobile:
,E-mail:
Work: Position:
Company Name:
Company
Address:
Business Phone:
Business Fax: Signature:

Date:

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