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*

YesNo
Date (completed or planned)*

DayMonthYear
Date
Current Syringe Driver Competency Certificate*

YesNo
Date (completed or planned)*

DayMonthYear
Date
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: