Poi Palliative Care Link Nurse Application

Poi Palliative Care Link Nurse

Application Form
Participant name

First NameLast Name
Role
Ethnicity
For data collection purposes
Email
example@example.com
Phone Number
Your Manager

First NameLast Name
Organisation Name
Local Hospice
Relevant Qualifications:
Relevant background in Palliative Care
Completed co-requisite training?

(Must be completed within 6 months of the Orientation workshop)
Fundamentals of Palliative Care Completed
Date (completed or planned)

DayMonthYear
2 digit day, 2 digit month, 4 digit yearDate
Current Syringe Driver Competency Certificate
Date (completed or planned)

DayMonthYear
2 digit day, 2 digit month, 4 digit yearDate
Goals and Objectives for participating in Link Nurse Programme:
Employer Endorsement
Name of Manager

First NameLast Name
Position:
Organisation:
Phone Number
Email
Poi Backfill Contribution to your Employer - $400 (excl GST) may be available to your employer. Please discuss with your local Poi Team manager to see if you are eligible as this funding is limited.

(Link Nurse Orientation Workshop attendance will need to occur before reimbursement)
Should be Empty: