Supervisor Training and Education Program (STEP)

Supervisor Training and Education Program (STEP) application form

Thank you for your interest in STEP. Please complete the application form below. You will be notified when your application has been received.

The program is limited to 160 participants within the Central and Western CPNs. Places will be allocated based on CPN need. If demand exceeds availability, unsuccessful applicants will be notified and placed on a waiting list. They will also receive priority status if future programs are offered.

Please note that there are no program fees for participants. The program is funded by the Central and Western CPNs.

You will receive notification that your application has been received.The closing date for applications is Wednesday 25 January 2012.

Question Title

* 1. Applicant details

First name:

Last name:

Organisation:

Health discipline:

Position:

Department/Ward/Faculty/Campus:

Work phone number:

Mobile or other phone number:

Email address:

Years of experience providing clinical supervision:

RACGP/ACRRM number (N/A if not applicable):

Dietary requirements:

Question Title

* 2. Select the preferred sessions:

Central CPN - Univ of Melbourne - all 4 sessions 4:15-8:15pm

Central CPN - Session 1: Tues 28/2/12

Central CPN - Session 2: Tues 20/3/12

Central CPN - Session 3: Tues 17/4/12

Central CPN - Session 4: Tues 1/5/12

Western CPN - Sunshine Hospital - all 4 sessions 4-8pm

Western CPN - Session 1: Thurs 23/2/12

Western CPN - Session 2: Thurs 22/3/12

Western CPN - Session 3: Thurs 19/4/12

Western CPN - Session 4: Thurs 3/5/12