2021 Enrolment Form Pack - BACHELOR OF NURSING - NorthTec
←
→
Page content transcription
If your browser does not render page correctly, please read the page content below
NorthTec Nursing Department
BACHELOR OF NURSING
Enrolment Form Pack
2021
1QUESTIONS
If you are unsure of anything in this ENROLMENT FORM PACK
our friendly Enquiries team make enrolling at NorthTec easy.
If you need help organising your enrolment contact them
today.
Call 0800 162 100 or email enquiries@northtec.ac.nz
2Enrolment Form Pack
ENROLMENT FORM PACK FOR BACHELOR OF NURSING
Use this checklist to ensure that you have completed all the correct forms and attached all the required documentation.
Registration Form
Supporting documentation required:
Documents to verify Identity and Citizenship
NZQA or National Student Number
IRD Number (if applicable)
Evidence of your marks/grades or NZQA record of learning
Additional Information Forms
Supporting documentation required:
English Language testing results
(if English is your second language, supply results of IELTS)
Police Vetting Consent Form
Supporting documentation required:
Documents to verify Subject’s Identification (if applicable)
Report on Applicant
Forms to be given to TWO referees to support application.
If the referees want the report to remain confidential, please post directly to NorthTec Registry Team.
Please note: When you complete and submit all forms you are NOT FULLY ENROLLED until:
• you have received formal written notification that your application has been successful;
• you have returned the 'offer of place' acceptance document to confirm your place on your programme of study.
You will receive this 'offer of place' with your formal notification.
34
Registration Form 2021 NorthTec is the
registered trading name
Private Bag 9019, Whangārei, 0148, New Zealand of Northland Polytechnic
Telephone: 09 470 3555 Facsimile: 09 470 3556 Freephone: 0800 162 100 www.northtec.ac.nz
Please refer to the attached guide before you complete this registration form 10. Completion: (Please refer to guide)
Do you expect to complete the academic requirements in order to complete your programme of
1. Name of the qualification you wish to enrol in: (Please refer to guide) study in this year of enrolment? Yes No
11. Payments: (Please refer to guide)
How do you intend to pay for your study?
Year of study:
Student loan Self Employer Fees free
1A. Place of study: (Please refer to guide) Training Incentive Allowance (T.I.A.) Other
Raumanga ASB Centre, Kensington Future Trades, Dyer Street Please specify if “Other”
Bay of Islands (Kerikeri) Kaikohe Kaitaia Kawakawa
Fees differ for International students. If domestic status students do not provide verification of identity
Auckland Extramural Online Other (see Guide Question 3) they will be considered to be full fee paying students.
Please specify if “Other”
12. Citizenship and residency: (Please refer to guide)
Tick the box which best describes your citizenship or permanent residency status.
2. If you wish to apply for another qualification at NorthTec i.e. your
New Zealand citizen New Zealand permanent resident
second choice, please detail: Australian citizen Australian permanent resident (living in NZ) Other
Please specify if “Other”
3. Print your full legal name: (Please refer to guide) (For students with dual citizenship, specify the country of citizenship on the passport used to enter
New Zealand).
Mrs Ms Miss Mr Other - specify If you ticked “Other”, please also specify your fee/assistance status.
01 NZAID scholarship (incl. Aotearoa, short-term training and post-graduate)
Family name:
03 Full fee paying foreign student (including those on current work visa)
04 Exchange scheme approved by Ministry of Education
First name(s):
08 Military personnel, diplomatic staff/family, or persons associated with Antarctic programmes
12 International ITO off-job trainee
Preferred first name:
13. During your time studying in this qualification will you be resident in
3A. Are you currently (this year) a NorthTec staff member Yes No New Zealand or overseas?
In New Zealand Overseas
4. Have you studied at NorthTec before? Yes No
14. Which area do you currently live in OR if you have moved to study at
If you answered “Yes”, what was your student ID Number
NorthTec, which area did you live in before you moved?
5. Have you previously enrolled at NorthTec under another name, or Whangārei Far North Bay of Islands Hokianga Mid North
are you known by another name? Kaipara Rodney District Auckland - North Shore Auckland region
Please detail: Other North Island South Island Overseas
Other - Specify
6. Date of birth: Day Month Year
15. Ethnicity: (Please refer to guide for codes)
Age What ethnic group(s) do you belong to? Please enter the three digit code from the guide. You may
enter up to three different ethnic groups; Selection 1 is the group you most identify with.
7. Gender: Male Female Diverse Selection 1 Selection 2 Selection 3
8. NZQA or National Student Number (NSN): (Please refer to guide)
- - Please specify if “Other”
9. Address and contact details: 15A.Iwi: (Please refer to Guide for codes)
Please advise promptly of any changes to the postal address given. If you identified as New Zealand Māori in any of the 3 selections in question 15, with which Iwi do you
identify? Please enter the four digit code from the guide. You may enter more than one Iwi:
Permanent postal address:
Selection 1 Selection 2 Selection 3
Postal code:
16. Secondary grades:
Home phone: Mobile phone:
What is the highest level of achievement you hold from a secondary school? Your highest
achievement may be a “traditional” award such as School Certificate, or you may have achieved
Home Email:
a number of credits or a National Certificate at a certain level on the National Qualifications
Framework. Your NZQA Record of learning shows you how many credits you have. Tick only one box.
Address while studying:
00 No formal secondary qualification
11 14 or more credits at any level
12 NCEA Level 1 or School Certificate
Postal code:
13 NCEA Level 2 or 6th Form Certificate
Home phone: Mobile phone:
Home email: 5Page 2 - NorthTec Registration Form 2021
14 University entrance 23. STUDENT DECLARATION AND CONDITIONS (Please refer to guide)
15 NCEA Level 3 or bursary or scholarship Privacy - NorthTec collects and stores information from this form to comply with the requirements of
the Ministry of Education and other Government agencies. The information is also used for internal
09 Overseas qualification (includes International Baccalaureate & Cambridge exams) processes such as student selection, surveys, marketing and administration. Information about
98 Other students may be supplied to, and sought from, other educational organisations for the purpose of
verifying academic records and providing information on student progress.
99 Not known When required by law, NorthTec releases information to Government agencies. You will find details of
Please specify if “Overseas qualification” the agencies that may be supplied with information in the NorthTec Registration guide.
In signing this Registration Form you authorise such disclosure on the understanding that NorthTec
will observe the general conditions governing the release of information, as set out in the Privacy Act
1993, the Education Act 1989 and other relevant legislation. You may see any information held about
17. What was the name of the last secondary school you attended? you and amend any errors in that information. To do so, contact the Registry.
State “overseas” if applicable. (Please refer to guide) Please note that your name, date of birth and residency as entered on this Registration Form will
be included in the National Student Index, and will be used in an Authorised Information Matching
programme with the New Zealand Birth Register. For further information please see http://www.nsi.
govt.nz/ima
17A.What was your last year at secondary school? (e.g. 1999) Fees - In signing this Registration Form you undertake to pay all fees as they become due, and
to meet any late fees and collection charges associated with debt recovery. NorthTec’s policy on
withdrawal and refund of fees may be obtained from the Enquiries office.
Rules - In signing this Registration Form you undertake to comply with the statutes, regulations, rules
and policies of NorthTec. (Refer to the Academic Calendar on www.northtec.ac.nz)
18. Please give your marks/grades/unit standards: (Please refer to guide)
Health and Safety - In signing this Registration Form you undertake to disclose, prior to enrolment,
Required for programmes longer than 2 weeks full-time all health information that might affect your ability to complete the programme or the health and
Please attach a copy of your marks/grades or NZQA record of learning safety of yourself or others. If you do not disclose all relevant information staff will be unable to
advise you appropriately and you may enrol on a programme that you are unable to complete.
19. Tertiary Study: (Please refer to guide) Declaration - I declare that to the best of my knowledge all the information supplied on and
Have you ever enrolled in a tertiary education institution (university, polytechnic, college of with this Registration Form is true and complete. I agree to abide by the conditions described
education, private training establishment, or wānanga) either in New Zealand or overseas since above, and I consent to the disclosure of personal information as described above.
leaving school? Do not include enrolments in STAR, community or hobby classes.
Yes No Applicant Signature: Date:
If you answered “Yes”, please complete the following details:
If you are under 18 years of age a parent/guardian must complete and sign the section below
Year you first enrolled in any tertiary study: to acknowledge acceptance of this declaration.
Title of latest qualification completed: Parent/Guardian Signature: Date:
Name of organisation you studied at:
Print Name:
Year of completion:
Address:
(Please attach copies of complete qualifications)
20. Prior activity: (Please refer to guide) You may tick only one box.
What was your MAIN activity or occupation in New Zealand last year?
01 Secondary school student 08 House-person or retired Postal Code:
02 Unemployed or other beneficiary (excl. retired) 09 Overseas (irrespective of occupation)
03 Wage or salary worker 11 Private training institute student Phone: ( ) Mobile:
04 Self-employed 12 Wānanga student Email:
05 University student
06 Polytechnic student
21. Disabilities/health: (Please refer to guide) 24. Further Information
This information is confidential to NorthTec but it could be used by the Student Advisors to obtain further For assistance freephone 0800 162 100.
resources and support that will assist you in your studies.
Do you live with the effects of significant health, injury, long term illness or disability? • NorthTec reserves the right to cancel or postpone any course for any reason.
• NorthTec does not guarantee that these courses/qualifications are suitable to any
Yes No
individual student and their particular requirements.
If you answered “Yes” above, indicate which of the following is affected:
• Each prospective student should make their own investigation as to whether the course/
Vision (serious impairment) Hearing (serious impairment)
qualification is suitable for their requirements.
Concentration/learning Communication/speech/written
• Fees differ for International Students.
Physical mobility impairment Other (please state)
• Fees must be paid in full either personally, by StudyLink or other third parties before the
Please specify other commencement of your study.
• Your enrolment cannot be confirmed until we have sighted complete documentary evidence of
Would you like to discuss your support needs or any specific requirements with the Student Advisors? your full legal name, date of birth and citizenship.
007 Registry_ NorthTec Registration Guide and Form
Yes No
If you answered “Yes” above, please make an appointment to see a Student Advisor.
22. Emergency contact details: (Please refer to guide) OFFICE USE ONLY - STUDENT ID
Name: Relationship:
Entered ARTENA / / Signed:
Phone: ( ) Mobile:
Passport no/BC no./NSN no.
Email:
Address if different from study address (stated in Question 9): Documentation sighted:
Invoice no. (Checked/date/signature)
6 Postal codeRegistration
Guide 2021 NorthTec is the registered trading name of Northland Polytechnic
Guide to Registration and Terms and Conditions
Remember ... there are 3 ways to Register.
1. Go to our website www.northtec.ac.nz and click on ‘APPLY NOW’ at the top of the page
2. Fill in the attached form and, together with any attachments, post to:
NorthTec Registry, Private Bag 9019, Whangārei Mail Centre, 0148.
3. Visit us at one of our campuses or Learning Centres.
Please read this Guide carefully. It is intended to help you through the process of registration.
For assistance freephone 0800 162 100.
CHECKLIST TOWARDS ENROLMENT QUESTION 1A - PLACE OF STUDY
Once you have completed your Registration Form, use this checklist
Please tick the campus or learning centre that you intend to study at:
to ensure that you have completed all sections and
attached all required documents. Extramural includes:
• by correspondence
Question 3: Documents to verify your Full Legal Name • distance learning (web-based/on-line)
Other includes:
Question 12: Documents to verify Citizenship
• any other site of delivery not listed above
Question 18: Evidence of school grades (if applicable)
Question 23: Signatures (Student Declaration and Conditions) QUESTION 3 - PRINT YOUR FULL LEGAL NAME
Completed all sections You must use the same name that is on your legal identification e.g.
Tear off completed Registration Form, attach documents, and birth certificate or passport, (or provide proof that it has changed e.g.
return to: marriage certificate/deed poll papers). Please copy exactly from your
NorthTec Registry, Private Bag 9019, birth certificate or passport.
Whangārei Mail Centre, 0148 The Ministry of Education requires us to establish your identity by
collecting and verifying (proving) your full legal name.
Please note: When you complete and submit a Registration Form, you
are NOT FULLY ENROLLED until: If this is the first time you have registered with NorthTec (or you have
• you have received formal written notification that your application never supplied documents in the past) you need to provide a verified
has been successful copy of evidence of your full legal name and age. If you have enrolled
• you have returned the 'offer of place' acceptance document to with us before, and your name has changed since your last enrolments,
confirm your place on your programme of study. You will receive this you will need to send us verified documentation to confirm that change.
'offer of place' with your formal notification. A verified copy of an original document is acceptable.
QUESTION 1 - QUALIFICATION YOU WISH TO ENROL IN A verified copy is a photocopy that has been confirmed and signed
R007 Registry_ NorthTec Registration Guide and Form
by an authorised person who has sighted the original document. An
Please write the full name of the qualification you will be studying e.g. authorised person is listed in the Oaths and Declarations Act of 1957.
New Zealand Diploma in Business. Examples include: Barrister or solicitor of the High Court, Justice of
the Peace (JP), Court Registrar or Deputy Registrar, Notary Public
PLEASE NOTE: Programmes are offered subject to final approval and/or or Member of Parliament. When a learner is in a remote community,
sufficient enrolments being received. a School Principal, Minister of the Church, General Practitioner or
member of the New Zealand Police is acceptable.
Alternatively you can take the original documents and Registration
Form to any NorthTec Campus or Learning Centre and a copy will be
taken for you.
7The following are examples of acceptable documents: (Do not send of fees is regarded seriously and NorthTec will take steps to obtain
originals) the required payment, including prohibiting students from class,
not releasing academic results, and referring unpaid debts to a debt
• Birth Certificate, Passport or Certificate of Citizenship (with place
collection agency for recovery action.
of birth stated as New Zealand, Cook Islands, Tokelau, Niue, or
Australia). If you need to obtain a birth certificate, contact Births, Note: Applicants who have not provided evidence of their status as a
Deaths and Marriages on 0800 22 52 52. If you have a credit card, domestic student could be invoiced at full cost fees.
you can order copies of certificates at that number.
• Overseas Passport with residency stamp, work permit or student QUESTION 12 - CITIZENSHIP AND RESIDENCY
permit for international students. Please tick the box that best describes your citizenship or residency
status. This question asks which country you are allowed to live in,
• Certificate of Identity (from the New Zealand Immigration Service).
i.e. if you were born in New Zealand tick NZ Citizen. If you were born
• Marriage Certificate or Deed Poll declaration (for change of legal in another country, and can prove you are a resident of NZ, tick NZ
name only). Permanent Resident.
• Statement of Whakapapa: A verified copy of a whakapapa statement QUESTION 15 - ETHNICITY
is acceptable only when a birth certificate cannot be obtained. Both
the learner and a kaumātua must sign the whakapapa as evidence of Which ethnic group or groups do you belong to? You may tick or write
identity and citizenship, and include date of birth. Please request a the codes for up to 3 groups that you have a family connection to.
template from Registry. Your first choice (Selection 1) should be the group you most identify
Note: Your enrolment cannot be confirmed until we have sighted with.
complete documentary evidence of your full legal name, date of birth 111 NZ European/Pakeha 121 British/Irish
and citizenship. 122 Dutch 123 Greek
124 Polish 125 South Slav
QUESTION 8 - NZQA or NATIONAL STUDENT NUMBER 126 Italian 127 German
Have you ever had a NZQA ID number (New Zealand Qualification 128 Australian 129 Other European
Authority Identification Number), or ROL Number (Record of Learning
211 New Zealand Māori 311 Samoan
Number), or NCEA (National Certificate of Education Achievement)? If
you have, fill in this box. If you are unsure of your ROL number leave the 321 Cook Island Māori 331 Tongan
box blank. NorthTec will then register your name with the MOE (Ministry 341 Niuean 351 Tokelauan
of Education) and request a NSN (National Student Number). 361 Fijian 371 Other Pacific Peoples
411 Filipino 412 Cambodian
Please note that your name, date of birth and residency as entered 413 Vietnamese 414 Other Southeast Asian
on this enrolment will be included in the National Student Index, and
421 Chinese 431 Indian
will be used in an Authorised Information Matching programme with
the New Zealand Birth Register. For further information please see: 441 Sri Lankan 442 Japanese
http://nsi.education.govt.nz/home.aspx 443 Korean 444 Other Asian
511 Middle Eastern 521 Latin American
QUESTION 10 - COMPLETION 531 African 611 Other
If your programme of study is one year or less, and you are expecting 999 Not Stated
to complete the qualification this year, tick Yes. If your programme will
take you longer than one year to complete, or if you do not expect to QUESTION 15A - IWI CODES
finish in this year of enrolment, tick No. Refer to Iwi codes on opposite page
QUESTION 11 - PAYMENTS
Please tell us how you intend paying for your study. If you are
applying for a Student Loan through StudyLink, they can be
contacted by phoning 0800 88 99 00 or Freepost 113907,
StudyLink Centre, Private Bag 11070, Palmerston North, 4442 or
www.studylink.govt.nz
If you intend to enrol on a NorthTec course, full or part-time, it is your
obligation to inform your WINZ Case Manager if you are currently in
receipt of a benefit, as you may not be entitled to continue to receive
WINZ income assistance. The contact phone number is 0800 559 009.
Fees are payable before your programme of study official start
date. NorthTec regards all students as valued clients, but also has
a responsibility to students who have paid their fees. Non-payment
8QUESTION 15A - Iwi
If you identified as ‘New Zealand Māori’ in the Ethnicity section, the Ministry of Education requires that you specify your Iwi. This list of Iwi codes
has been compiled by Statistics New Zealand. Please select up to three Iwi codes from this list and enter the four digit code(s) in the Iwi section.
01 Te Tai Tokerau/Tāmaki-makaurau 0510 Ngāti Whare 1101 Te Atiawa (Te Waipounamu/South Island)
(Northland/Auckland) Region 0511 Ngā Pōtiki ā Tamapahore 1102 Ngāti Koata
0512 Te Upokorehe 1103 Ngāti Kuia
0101 Te Aupōuri 0513 Ngāti Tūwharetoa ki Kawerau 1104 Kāti Māmoe
0102 Ngāti Kahu 1105 Moriori
0103 Ngāti Kurī 06 Te Tairāwhiti (East Coast) Region 1106 Ngāti Mutunga (Wharekauri/Chatham Islands)
0104 Ngāpuhi 1107 Rangitāne (Te Waipounamu/South Island)
0105 Ngāpuhi ki Whaingaroa-Ngāti Kahu ki Whaingaroa 0601 Ngāti Porou 1108 Ngāti Rārua
0106 Te Rarawa 0602 Te Aitanga-a-Māhaki 1109 Ngāi Tahu / Kāi Tahu
0107 Ngāi Takoto 0603 Rongowhakaata 1110 Ngāti Tama (Te Waipounamu/South Island)
0108 Ngāti Wai 0604 Ngāi Tāmanuhiri 1111 Ngāti Toarangatira (Te Waipounamu/South Island)
0109 Ngāti Whātua (not Ōrākei or Kaipara) 0605 Te Aitanga ā Hauiti 1112 Waitaha (Te Waipounamu/South Island)
0110 Te Kawerau ā Maki 1113 Ngāti Apa ki Te Rā Tō
0111 Te Uri-o-Hau 07 Te Matau-a-Māui/Wairarapa (Hawke’s
0112 Te Roroa Bay/Wairarapa) Region 20/23 Iwi Not Named, but Waka or Iwi Confederation Known
0113 Ngāti Whātua o Kaipara
0114 Ngāti Whātua o Ōrākei 0701 Rongomaiwahine (Te Māhia) 2001 Tainui, iwi not named
0115 Ngāi Tai ki Tāmaki 0702 Ngāti Kahungunu ki Te Wairoa 2002 Te Arawa, iwi not named
0116 Ngāti Hine (Te Tai Tokerau) 0703 Ngāti Kahungunu ki Heretaunga 2003 Tākitimu, iwi not named
0117 Te Paatu 0704 Ngāti Kahungunu ki Wairarapa 2004 Aotea, iwi not named
0118 Ngāti Manuhiri 0706 Rangitāne 2005 Mātaatua, iwi not named
0119 Ngāti Rēhua (Te Matau-a-Māui/Hawke's Bay/Wairarapa) 2006 Mahuru, iwi not named
0707 Ngāti Kahungunu ki Te Whanganui-a-Orotu 2007 Māmari, iwi not named
02 Hauraki (Coromandel) Region 0708 Ngāti Kahungunu ki Tamatea 2008 Ngātokimatawhaorua, iwi not named
0709 Ngāti Kahungunu ki Tamakinui a Rua 2009 Nukutere, iwi not named
0201 Ngāti Hako 0710 Ngāti Pāhauwera 2010 Tokomaru, iwi not named
0202 Ngāti Hei 0711 Ngāti Rākaipaaka 2011 Kurahaupō, iwi not named
0203 Ngāti Maru (Hauraki) 0712 Ngāti Hineuru 2012 Muriwhenua, iwi not named
0204 Ngāti Paoa 0713 Maungaharuru Tangitū 2013 Hauraki / Pare Hauraki, iwi not named
0205 Patukirikiri 0714 Rangitāne o Tamaki nui ā Rua 2014 Tūranganui a Kiwa, iwi not named
0206 Ngāti Porou ki Harataunga ki Mataora 0715 Ngāti Ruapani ki Waikaremoana 2015 Te Tauihu o Te Waka a Māui, iwi not named
0207 Ngāti Pūkenga ki Waiau 0716 Te Hika o Pāpāuma 2016 Tauranga Moana, iwi not named
0208 Ngāti Rāhiri Tumutumu 2017 Horouta, iwi not named
0210 Ngāti Tamaterā 08 Taranaki (Taranaki) Region 2018 Mōkai Pātea, iwi not named
0211 Ngāti Tara Tokanui 2101 Te Atiawa, region not known
0212 Ngāti Whanaunga 0801 Te Atiawa (Taranaki)
0802 Ngāti Maru (Taranaki) 2102 Ngāti Haua, region not known
0803 Ngāti Mutunga (Taranaki) 2103 Ngāti Maru, region not known
03 Waikato/Te Rohe Pōtae (Waikato/King Country) Region 2104 Ngāti Mutunga, region not known
0804 Ngā Rauru
0301 Ngāti Haua (Waikato) 0805 Ngā Ruahine 2105 Rangitāne, region not known
0302 Ngāti Maniapoto 0806 Ngāti Ruanui 2106 Ngāti Raukawa, region not known
0303 Raukawa (Waikato) 0807 Ngāti Tama (Taranaki) 2107 Ngāti Tama, region not known
0304 Waikato 0808 Taranaki 2108 Ngāti Toa, region not known
0305 Ngāti Te Ata 0809 Tangāhoe 2109 Waitaha, region not known
0306 Ngāti Hīkairo 0810 Pakakohi 2110 Ngāti Apa, region not known
0307 Rereahu 2111 Ngāi Tai, region not known
0308 Ngāti Tiipa 09 Whanganui/Rangitīkei (Wanganui/Rangitīkei) Region 2112 Ngāti Kahungunu, region not known
0309 Ngāti Korokī Kahukura 2113 Ngāti Tūwharetoa, region not known
0310 Ngāti Tamaoho 0901 Ngāti Apa (Rangitīkei) 2201 Hapū Affiliated to More Than One Iwi
0311 Te Ākitai-Waiohua 0902 Te Ati Haunui-a-Pāpārangi 2301 Te Tai Tokerau/Tāmaki-makaurau Region, Iwi not named
0903 Ngāti Haua (Taumarunui) 2302 Hauraki Region, Iwi not named
04 Te Arawa/Taupō (Rotorua/Taupō) Region 0904 Ngāti Hauiti (Rangitīkei) 2303 Waikato/Te Rohe Pōtae Region, Iwi not named
0905 Ngāti Whitikaupeka (Rangitīkei) 2304 Te Arawa/Taupō Region, Iwi not named
0401 Ngāti Pikiao (Te Arawa) 0906 Ngāi Te Ohuake (Rangitīkei) 2305 Tauranga Moana/Mātaatua Region, Iwi not named
0402 Ngāti Rangiteaorere (Te Arawa) 0907 Ngāti Tamakōpiri (Rangitīkei) 2306 Te Tai Rāwhiti Region, Iwi not named
0403 Ngāti Rangitihi (Te Arawa) 0908 Ngāti Rangi (Ruapehu, Whanganui) 2307 Te Matau-a-Māui/Wairarapa Region, Iwi not named
0404 Ngāti Rangiwewehi (Te Arawa) 0909 Uenuku (Ruapehu, Waimarino) 2308 Taranaki Region, Iwi not named
0405 Tapuika (Te Arawa) 0910 Tamahaki (Ruapehu, Waimarino) 2309 Whanganui/Rangitīkei Region, Iwi not named
0406 Ngāti Tarāwhai (Te Arawa) 0911 Tamakana (Ruapehu, Waimarino) 2310 Manawatū/Horowhenua/Te Whanganui-a-Tara Region,
0407 Tūhourangi (Te Arawa) Iwi not named
0408 Uenuku-Kōpako (Te Arawa) 2311 Te Waipounamu/Wharekauri Region, Iwi not named
0409 Waitaha (Te Arawa) 10/11 Manawatū/Horowhenua/Te Whanganui-a-Tara
0410 Ngāti Whakaue (Te Arawa) (Manawatū/Horowhenua/Wellington) Region 50/99 Other
0411 Ngāti Tūwharetoa (ki Taupō)
0412 Ngāti Tahu-Ngāti Whaoa (Te Arawa) 1001 Te Atiawa (Te Whanganui-a-Tara/Wellington) 5000 Do not know name of Iwi
0413 Ngāti Mākino 1002 Muaūpoko 5555 Refused to Answer
0414 Ngāti Kearoa / Ngāti Tuarā 1003 Rangitāne (Manawatū) 6000 Unidentifiable response
0415 Ngāti Rongomai (Te Arawa) 1004 Ngāti Raukawa (Horowhenua/Manawatū) 8888 Response outside scope
1005 Ngāti Toarangatira 9999 Not Stated
05 Tauranga Moana/Mātaatua (Bay of Plenty) Region (Te Whanganui-a-Tara/Wellington)
1006 Te Atiawa ki Whakarongotai
0501 Ngāti Pūkenga 1007 Ngāti Tama ki Te Upoko o Te Ika
0502 Ngāi Te Rangi (Te Whanganui-a-Tara/Wellington)
0503 Ngāti Ranginui 1008 Ngāti Kauwhata
0504 Ngāti Awa 1009 Ngāti Tukorehe
0505 Ngāti Manawa
0506 Ngāi Tai (Tauranga Moana/Mātaatua)
0507 Tūhoe
0508 Whakatōhea
0509 Te Whānau-ā-Apanui
9QUESTION 17 and 17A - SECONDARY SCHOOL STUDY PRIVACY ACT
The Ministry of Education requires us to collect information on the last (IN RELATION TO STUDENT DECLARATION)
New Zealand secondary school you attended as well as the last year
you attended school. NorthTec is required to collect and maintain student personal
information in a way that is consistent with the principles outlined
You must supply these details, otherwise we will be unable to confirm in the Privacy Act 1993, the Education Act 1989 and other relevant
your enrolment. legislation.
NOTE:
QUESTION 18 - MARKS, GRADES, UNIT STANDARDS The information collected during the registration process will only
AND PREVIOUS EMPLOYMENT EXPERIENCE be released to any of the following potential users on a “need to
(only required for programmes longer than 2 weeks full-time). know” basis. You have the right to see and correct, if necessary, the
To carry out the selection process, it is advisable to supply us with a information provided.
copy of your school grades and NZQA record of learning. If you are 1. The personal information collected at the time of your final
a mature student, and you do not have copies, a current Curriculum enrolment will be held on the student administration database
Vitae is acceptable. and will be made available only to staff of NorthTec, i.e. those
responsible for:
QUESTION 19 - TERTIARY STUDY • the selection of applicants
Tertiary study is study taken after you have left secondary school • your enrolment
(but excludes STAR, community or hobby courses). If you have • establishing and maintaining your academic records
enrolled in tertiary study before, answer ‘Yes’ to the question • providing tuition, appropriate academic advice and
asked and complete the remainder of the section. If you have support
completed more than one qualification, please provide details on a • providing student services
separate sheet and attach to the form, together with copies of these • maintaining order and discipline
qualifications. • graduation
• library services
QUESTION 20 - PRIOR ACTIVITY • institutional research
The Ministry of Education requires us to report on your MAIN • marketing
occupation or activity in New Zealand on 1 October of the year prior to
If you wish to be excluded from any printed graduation material or
your first year of study with NorthTec.
advertisement, please advise the Academic Registrar in writing.
QUESTION 21 - DISABILITIES/HEALTH 2. Some personal information from this database may be made
available to the following external organisations upon legitimate
The Ministry of Education requires us to report on the numbers of
request, or when required by law:
students with disabilities who enrol with us. If you tell us that you
• The Ministry of Education
have a disability, we may be able to assist you with your studies. For
• Tertiary Education Commission (TEC)
enquiries, contact Registry on (09) 470 3893 or 0800 808 856 ext
• New Zealand Qualifications Authority
3893 who will put you in contact with our Student Success team for
• Ministry of Social Development (Student Loans &
more information.
Allowances)
QUESTION 22 - EMERGENCY CONTACT DETAILS • IRD (Student Loans)
• Department of Immigration (for non-New Zealand
NorthTec needs to have the name, address and phone numbers of a citizens/permanent residents)
person who can be called in case there is an emergency. This can be • Agencies that support particular students through
your partner, family member or a close friend. scholarships and prizes, payment of fees and other
awards (e.g. tribal trusts)
QUESTION 23 - STUDENT DECLARATION AND • Industry Training Organisations
CONDITIONS • Education and Training Support Agency
Students 18 years of age and older must date and sign the • Special Education Services (for Manaaki Tauira applicants)
declaration to accept the conditions of registration. • Other tertiary institutions (conjoint programmes or
Students under 18 years of age are required to obtain a parent/ transfer of academic records)
guardian to sign and date the declaration on the student’s behalf. • Ministry of Foreign Affairs and Trade (Ministry funded
international students)
Students under 16 years of age, at the time of enrolment, need to
• Foreign institutions (for exchange students)
provide Ministry of Education documentation to exempt attendance
• Professional registration/licensing agencies
at secondary school (MOE Exemption).
(e.g. Teacher Registration Board)
• New Zealand Vice Chancellors’ Committee
• The media (if lists of graduates are published)
• NZ Police, Department of Justice, Inland Revenue
Department, National Students Services Centre, Work
and Income New Zealand and Accident Compensation
Corporation (for approved data matching and the
maintenance of law and order as defined in the Privacy Act)
• Employers, provided that a privacy waiver has been signed by
you, the student
10 • Your last Secondary School.ADDITIONAL INFORMATION FORM
APPLICANTS NAME:
PERSONAL STATEMENT
Please outline why you have chosen nursing as a career and describe the personal qualities and relevant
aspects from your life experience which will enhance your application. Please include information on
hobbies, interests and involvement in community activities e.g. sports groups, church, volunteer work etc.
(Approximately 300 words). This section must be completed, in your own handwriting, by Applicant.
11ADDITIONAL INFORMATION FORM
ENTRY REQUIREMENTS
A) Complete the box below and attach a verified copy of your results from any secondary and/or tertiary study
or training. If you are a current Year 13 school student please list subjects enrolled in for NCEA Level 3.
School/Tertiary School subject/ For school study only For non-school study only
Institution/Training Course Title NCEA Details Qualification/programme of
Provider Study/Training Course
Level Credits Year (e.g. Certificate in ....)
Note: If you are studying this year, you will need to ensure that you have the results for this study prior to the
start of your programme. Attach additional papers if required.
B) Additional supporting documentation: Attach any other supporting documentation required for this
programme (e.g. CV/Portfolio, letter of support from employer)
C) English language requirements: Is English your first language? YES ¨ NO ¨ (Please tick)
If NO, specify language:
and attach verified copies of any English testing (e.g. IELTS, OET) you may have.
Entry Notes: If you believe you meet the academic, English or other entry requirements with alternative
evidence (e.g. work experience, other study or training), please contact us to assess your eligibility for this
programme.
WORK and LIFE EXPERIENCE
Please list previous work experience.
Date From/To Employer Nature of Work / Responsibilities
12ADDITIONAL INFORMATION FORM
PREVIOUS NURSING STUDY
Please indicate any other Nursing programme(s) you have previously enrolled in, at this Polytechnic or
another educational facility. Include institute, name of programme and date.
HEALTH
While health issues are not usually a barrier to acceptance into the BN programme, the following questions
help us determine whether you have any health issues that may affect your ability to practice safely. As
some health issues may make it difficult to manage clinical practice and/or full-time study, the Selection
Committee may wish to discuss these with you to determine any support you may require if you are
successful with your application.
Do you have any current or long-term physical health issues? YES ¨ NO ¨ (Please tick)
If you answered yes, please provide details below:
_________________________________________________________________________________
_________________________________________________________________________________
Do you have any current or long term mental health issues? YES ¨ NO ¨ (Please tick)
If you answered yes, please provide details below:
_________________________________________________________________________________
_________________________________________________________________________________
Do you have any drug or alcohol related problems or have you received treatment for either in the past?
YES ¨ NO ¨ (Please tick) If you answered yes, please provide details below:
_________________________________________________________________________________
_________________________________________________________________________________
Do you require regular or periodic treatment from medical/health practitioners?
YES ¨ NO ¨ (Please tick) If you answered yes, please provide details below:
_________________________________________________________________________________
_________________________________________________________________________________
In the last five years, have you had any major illness requiring medication or other forms of treatment?
YES ¨ NO ¨ (Please tick) If you answered yes, please provide details below:
_________________________________________________________________________________
_________________________________________________________________________________
Please note NorthTec may require you to undergo a medical examination by a Health Practitioner. The
findings of this examination will be made available to the Selection Committee.
13ADDITIONAL INFORMATION FORM
CONVICTIONS AGAINST THE LAW
Have you ever been convicted of or facing charges for a criminal offence (apart from minor traffic
infringements)?
YES ¨ NO ¨ (Please tick) If you answered yes, please provide details below:
_________________________________________________________________________________
_________________________________________________________________________________
While a conviction may not stop you from being accepted into the programme, please note that any
conviction/s will be discussed at your interview.
Failure to disclose previous convictions when applying may jeopardise your enrolment into the programme.
If you are offered a place on the programme, you will be required to complete an “Authorisation to Disclose
Information” form, which is forwarded to the Licensing & Vetting Centre of the New Zealand Police. Your
acceptance will be conditional upon a satisfactory police check being received.
What is Police Vetting?
Vetting, as conducted by the Licensing & Vetting Service Centre, searches the Police database for any
information held about the subject of the vet, not just convictions. Criminal conviction information is
released in accordance with the Criminal Records (Clean Slate) Act 2004. Where a criminal record may
be released, a printout is made of conviction history, location of the court, date of the offence, the offence
itself, and the sentence imposed. Minor traffic infringements, such as parking tickets, are not on these
printouts.
Where vetting indicates behaviour of a violent or sexual nature which has not, for whatever reason, resulted
in a conviction, the Police may recommend that an individual does not have unsupervised access to
children, young people or more vulnerable members of society.
The Results of Vetting
Once we have received the results of the Police Vetting, any concerns will be discussed with the student
and the Programme Leader. If these concerns are of a serious nature, they could jeopardise the student’s
on going enrolment in the programme. The information supplied by the Police will be securely stored until
such a time as it is no longer useful for the purpose it was obtained.
Nursing Council Requirements
The Nursing Council of New Zealand requires all candidates applying to be registered as a nurse to declare
any court convictions. All candidates for registration must demonstrate they are fit to be a Registered Nurse.
Nursing is a regulated profession governed by the Health Practitioners Competence Assurance Act 2003.
DECLARATION
I understand that making a false statement is an offence under the Crimes Act 1961.
Pursuant to Principle 11(d) of the Privacy Act 1993, I agree to the disclosure and use of the information on
this form by NorthTec to authorised bodies in response to requests under statutory authority.
I hereby declare that the information I have given above is true and correct, and that documentation
provided are verified copies of genuine documents. No information that has been provided is incorrect. No
information which could have a material bearing on my enrolment has been withheld. I understand that
under the Privacy Act 1993, I have the right of access to all personal information held by the Polytechnic
about me, and I also have the right to correct any information which is inaccurate. I have an obligation to
advise the Polytechnic of any changes to the personal information I have provided when this occurs.
Full Name of Applicant ___________________________________ Signature
14ADDITIONAL INFORMATION FORM
ASSESSMENT OF RISK
FOR BACHELOR OF NURSING APPLICANT
During your programme of study it is expected that you will be working with children.
The Vulnerable Children Act 2014 requires us to undertake a risk assessment of you with respect to the
safety of children.
Please answer the questions below:
1. Is there any reason, including past events, you might be perceived to pose a risk to children?
2. Can you tell us about your experience working with children; throughout this experience have you
encountered any particular challenges or difficulties; what where they and how did you respond to them?
3. Do you have any convictions that would preclude you from being engaged as a children’s worker?
4. Are there any investigations or other matters that may be disclosed in the safety checking process?
1516
Vetting Service NZPVS-CS – 05/19
Request & Consent Form
Section 1: Approved Agency to complete (For more information please see the Guide to Completing the
Consent Form - http://www.police.govt.nz/advice/businesses-and-organisations/vetting/forms-and-guides)
Name of Approved Agency submitting vetting request:
Northland Polytechnic – Registry (NorthTec)
Name of Applicant to be vetted:
Description of Applicant’s role:
Student Nurse
Applicant’s purpose
Employee Contractor/Consultant Volunteer Prosecution
Vocational Training Licence/Registration Visa/Work Permit Other
What group(s) will the applicant have contact with in their role for your agency?
Children/Youth Elderly Other Vulnerable Adults Other
What is the applicant’s primary role for your agency?
Caregiving (Children) Caregiving (Vulnerable adults) Healthcare Education Other
Will the role take place in the applicant’s home?
No Yes
Will the applicant be a volunteer or paid for their role?
Volunteer Paid
Is this request mandatory under the Children’s Act 2014 (CA)?
Yes: Core childrens worker Yes: Non-core childrens worker
No (mandatory under other legislation/optional/standard Police Vet)
If this is a mandatory Children’s Act request, please specify the check reason below:
New Children’s Worker Existing Children’s Worker CA Renewal
Evidence of Identity (to be completed by agency representative/delegate or identity referee - see guide for details)
A primary ID has been sighted (Mandatory) A secondary ID has been sighted (Mandatory)
One form of ID is photographic (Mandatory) Evidence
of name change has been sighted (if applicable)
OR: If your organisation is able to accept a verified RealMe identity then:
An assertion of a RealMe identity has been received (see guide for further information).
In making this request, I confirm that:
I have complied and will comply with the Approved Agency Agreement
I am satisfied with the correctness of the applicant’s identity
I have obtained the Applicant’s authorisation to submit this vetting request as set out in section 3 of this form
Approved Agency Authorised Representative:
Name: Sarah Bray Date:
Signature: Electronic
Signature
Page 1 of 3
17Vetting Service NZPVS-CS – 05/19
Request & Consent Form
Name of Approved Agency submitting vetting request:
Northland Polytechnic – Registry (NorthTec)
Section 2: Applicant to complete and return to Approved Agency
*Denotes a mandatory field
Personal Information
Details (note: the name you are most commonly known by is your primary name)
*Family name (Primary):
Given name(s):
(M) (F) (Other) *Date of birth:
*Gender: (dd/mm/yyyy)
Place of birth:
(Town/City/State)
*Country of birth
NZ Driver Licence
number:
Previous names: If applicable, please include other alias or alternate names; married name if not your primary name;
previous/maiden/name changed by deed poll or statutory declaration.
Family name First name Middle names
Permanent Residential Address
*Number/Street:
Suburb: Post Code:
*City/Town/
Rural District:
18
Page 2 of 3Vetting Service NZPVS-CS – 05/19
Request & Consent Form
Section 3: Applicant to complete and return to Approved Agency
Consent to release information
1. The New Zealand Police may release any information they hold if relevant to the purpose of this vetting request.
This includes:
Conviction histories and infringement/demerit reports
Active investigations, charges and warrants to arrest
Charges that did not result in a conviction including those that were acquitted, discharged without conviction,
diverted or withdrawn
Any interaction I have had with New Zealand Police considered relevant to the role being vetted, including
investigations that did not result in prosecution
Information regarding family violence where I was the victim, offender or witness to an incident or offence,
primarily in cases where the role being vetted takes place in a home environment where exposure to physical
or verbal violence could place vulnerable persons at emotional or physical risk.
Information subject to name suppression where that information is necessary to the purpose of the vet
2. If I am eligible under the Criminal Records (Clean Slate) Act 2004, my conviction history will not be released unless:
a. Section 19(3) of the Clean Slate Act applies to this request (exceptions to the clean slate regime)
b. Section 31(3) of the Children’s Act 2014 applies to this request (safety checks of core children’s workers).
c. The vetting request is made by an individual for the purpose of an overseas Visa/Work Permit as a Privacy Act
request authorising the vetting result to be provided directly to the relevant embassy, high commission or
consulate.
Please see the guide for more information regarding the Clean Slate legislation.
3. The Police Vetting Service may disclose newly-obtained relevant information to the Approved Agency after the
completion of the Police Vet in the following circumstances:
The disclosure of the newly-obtained information is considered to be justified under the Privacy Act 1993 (if it
had existed or been available at the time of the Police vet, it would have been disclosed); and
The Police Vetting Service has taken steps to confirm that the purpose of the Police vet still exists – e.g.that I
got the role which required a Police vet and am still employed or engaged in it.
The Vetting Service will endeavour to notify you prior to the disclosure.
4. Information provided in this consent form may be used to update New Zealand Police records.
5. I am entitled to a copy of the vetting result released to the Approved Agency (to be provided by the agency) and can
seek a correction by contacting the Vetting Service.
6. The Approved Agency will securely dispose of this consent form, copies of identification documents and the vetting
result within 12 months of receiving the result unless a longer retention period is required by legislation.
7. I may withdraw this consent, prior to Police’s disclosure of the vetting result, by notifying the Approved Agency.
For further information, please see the Guide to Completing the Consent Form.
Applicant’s Authorisation:
I confirm that the information I have provided in this form relates to me and is correct.
I have read and understood the information above.
I authorise New Zealand Police to disclose any personal information it considers relevant to my application (as
described above) to the Approved Agency making this request for the purpose of assessing my suitability at any time.
Name: Date:
Electronic
Signature:
Signature
19
Page 3 of 320
ACADEMIC RECORDS
REQUEST FORM
Complete Part A of the Transcript Request Form and SEND TO THE SCHOOL OF NURSING/NURSING
DEPARTMENT WHERE YOU UNDERTOOK YOUR NURSING PROGRAMME
Academic Records Request Form
This Form applies to students who have undertaken/completed their study of Nursing in another country (not New
Zealand) if you wish to apply for credit recognition.
Part A: TO BE COMPLETED BY APPLICANT
Complete part A of the Transcript request form and send to the school of nursing/nursing department where you
undertook your nursing programme
A
Full name:
Previous name (if applicable)
Date of Birth (dd/mm/yy)
Postal address
Name and
address of school
of Nursing
Qualification title Date completed
eg Bachelor of
Nursing
Name of Nursing Council or
State Regulatory Authority
Part B: TO BE COMPLETED BY THE SCHOOL OF NURSING
Note to the Head of Department, School of Nursing. Please attach the following documents, which must be signed and
dated by the Head of School and bear the official seal of the School or Department or Institution.
A transcript of the applicant’s nursing programme.
A statement of the hours of theoretical instruction per subject and the hours of clinical experience in all clinical
areas (if applicable).
The nursing programme syllabus and course descriptors that detail the contents of each subject of the nursing
programme.
Each applicant will be assessed in the terms of their equivalence to a comparable programme in New Zealand.
Accreditation of nursing programme from relevant Nursing Council and State Regulatory Please tick
Authority
Please provide verified evidence that the School of Nursing was approved by the relevant or appropriate Nursing Council
(NC) and the State Regulatory Authority (SRA) during the period that the above named student was enrolled with your
School. Please attach evidence of accreditation to this form. Examples of evidence include a copy of the letter from the
appropriate NC or the SRA that confirms the School is accredited. Evidence must be supplied for each year that the above
named student was enrolled in the Nursing programme
21ACADEMIC RECORDS REQUEST FORM
Has the Course of study leading to the qualification been shortened because of any Please
tick
prior education?
If this applicant’s nursing course of study has been shortened because of any recognised prior education, please supply
detailed evidence of the approved credit recognition assessment.
Name of School of Nursing, eg:
hospital/college/university
Qualification title, eg:
Bachelor of Nursing,
Diploma, Associate Degree
Language of instruction, eg:
English – please specify
Programme start date Programme
completion date
Name and title of official
completing this form
Contact details eg telephone
and email address
Authorised Signature (Principal of the School):
___________________________________________Date:______________________________
Yes. The applicant’s academic records are attached to this form.
Please send this form and Academic Records directly to North Tec at the address below:
North Tec:
Attention: Programme Leader Nursing Department Place school seal here:
51 Raumanga Valley Road
Raumanga
Whangarei 0140
New Zealand
22REPORT ON APPLICANT REFEREE 1
REPORT ON APPLICANT
This form must be completed by two professional or educational referees
to support the applicants enrolment in Bachelor of Nursing Programme
Applicants Full name:
Applicants Address:
Please see notes over page before completing this form.
Please place a cross (X) on the scale to indicate your assessment of the applicant in relation to each of the
qualities listed below.
PERSONAL QUALITIES
Honest ¨ ¨ ¨ ¨ ¨ ¨ Dishonest
Mature ¨ ¨ ¨ ¨ ¨ ¨ Immature
Reliable ¨ ¨ ¨ ¨ ¨ ¨ Unreliable
Positive regard for individuals ¨ ¨ ¨ ¨ ¨ ¨ Intolerant of some people
Culturally aware ¨ ¨ ¨ ¨ ¨ ¨ Culturally insensitive
Leadership ability ¨ ¨ ¨ ¨ ¨ ¨ No leadership ability
Comments:
INTERPERSONAL RELATIONSHIPS
Relationships with peers: Friendly, supportive ¨¨¨¨¨ ¨ Domineering or withdrawn
Relationships with people Open, constructive ¨¨¨¨¨ ¨ Tense, defensive
with authority:
Consideration for others: Accepting, considerate ¨¨¨¨¨ ¨ Self centered, judgemental
Communication skills with others: Effective, clear ¨¨¨¨¨ ¨ Vague, inconsistent
Comments:
ATTITUDES TO WORK/STUDY
Perserverance: Appropriately persistent ¨¨ ¨ ¨ ¨ ¨ Easily distracted
Cooperation with others: Participative ¨¨ ¨ ¨ ¨ ¨ Isolated
Application to work/study: Excellent ¨¨ ¨ ¨ ¨ ¨ Poor
Acceptance of correction: Accepting questions appropriately ¨¨ ¨ ¨ ¨ ¨ Resistant, defensive
Initiative: Motivated, appropriately independent ¨¨ ¨ ¨ ¨ ¨ Awaits direction
Information seeking: Enquiring ¨¨ ¨ ¨ ¨ ¨ Uninterested
Comments:
23REPORT ON APPLICANT REFEREE 1
GENERAL
Please add any general comment about the applicant’s performance at work/school.
Is attendance acceptable? YES ¨ NO ¨ (Please tick) If NO, please explain:
Do you consider the applicant able to undertake a fulltime 3 year programme of intensive study and a
significant clinical component? YES ¨ NO ¨ (Please tick)
Comments:
Is the information in this “Report on Applicant” to be kept confidential from the applicant?
YES ¨ NO ¨ (Please tick)
Signature
Full name: Date:
Address:
Relationship to applicant (employer, teacher etc.)
NOTES
• The statement which schools provide for school leavers is an acceptable alternative to this reference
form.
• The information and opinion provided in this report constitute “personal information” in terms of the
Privacy Act 1993. The person about whom this information and opinion are provided (the applicant)
is entitled to have access to this report under IPP6 and to seek correction of this report under IPP7.
Information or opinion provided in this report may be disclosed under IPP11 to the applicant and
members of the Selection Committee.
PLEASE RETURN THIS FORM AFTER COMPLETION TO THE APPLICANT WHO IS RESPONSIBLE
FOR ITS RETURN TO NORTHTEC ENQUIRIES & ENROLMENTS (UNLESS IT IS TO BE KEPT
CONFIDENTIAL). IF CONFIDENTIAL, PLEASE POST TO:
ENQUIRIES AND ENROLMENTS, PRIVATE BAG 9019, WHANGAREI, 0148
ADMINISTRATION ONLY:
RECEIVED: VIEWED:
24REPORT ON APPLICANT REFEREE 1
REFEREE CHECK
FOR BACHELOR OF NURSING APPLICANT
In order to meet the requirements of the Vulnerable Children Act 2014 we are required to seek information
from you to determine if the applicant poses a risk to the safety of children.
Please answer the questions below:
1. In what capacity do you know the applicant?
2. How long have you known the applicant?
3. Do you have any concerns about the applicant’s suitability to work with children?
4. Would you be happy for the applicant to take care of your children?
5. Are there any other comments you would like to make?
6. Are there any matters you would like to discuss by phone?
Referee’s Full name: Signature: Date:
2526
REPORT ON APPLICANT REFEREE 2
REPORT ON APPLICANT
This form must be completed by two professional or educational referees
to support the applicants enrolment in Bachelor of Nursing Programme
Applicants Full name:
Applicants Address:
Please see notes over page before completing this form.
Please place a cross (X) on the scale to indicate your assessment of the applicant in relation to each of the
qualities listed below.
PERSONAL QUALITIES
Honest ¨ ¨ ¨ ¨ ¨ ¨ Dishonest
Mature ¨ ¨ ¨ ¨ ¨ ¨ Immature
Reliable ¨ ¨ ¨ ¨ ¨ ¨ Unreliable
Positive regard for individuals ¨ ¨ ¨ ¨ ¨ ¨ Intolerant of some people
Culturally aware ¨ ¨ ¨ ¨ ¨ ¨ Culturally insensitive
Leadership ability ¨ ¨ ¨ ¨ ¨ ¨ No leadership ability
Comments:
INTERPERSONAL RELATIONSHIPS
Relationships with peers: Friendly, supportive ¨¨¨¨¨ ¨ Domineering or withdrawn
Relationships with people Open, constructive ¨¨¨¨¨ ¨ Tense, defensive
with authority:
Consideration for others: Accepting, considerate ¨¨¨¨¨ ¨ Self centered, judgemental
Communication skills with others: Effective, clear ¨¨¨¨¨ ¨ Vague, inconsistent
Comments:
ATTITUDES TO WORK/STUDY
Perserverance: Appropriately persistent ¨¨¨ ¨¨¨ Easily distracted
Cooperation with others: Participative ¨¨¨ ¨¨¨ Isolated
Application to work/study: Excellent ¨¨¨ ¨¨¨ Poor
Acceptance of correction: Accepting questions appropriately ¨¨¨ ¨¨¨ Resistant, defensive
Initiative: ¨¨¨ ¨¨¨
Motivated, appropriately independent Awaits direction
Information seeking: Enquiring ¨¨¨ ¨¨¨ Uninterested
Comments:
27REPORT ON APPLICANT REFEREE 2
GENERAL
Please add any general comment about the applicant’s performance at work/school.
Is attendance acceptable? YES ¨ NO ¨ (Please tick) If NO, please explain:
Do you consider the applicant able to undertake a fulltime 3 year programme of intensive study and a
significant clinical component? YES ¨ NO ¨ (Please tick)
Comments:
Is the information in this “Report on Applicant” to be kept confidential from the applicant?
YES ¨ NO ¨ (Please tick)
Signature
Full name: Date:
Address:
Relationship to applicant (employer, teacher etc.)
NOTES
• The statement which schools provide for school leavers is an acceptable alternative to this reference
form.
• The information and opinion provided in this report constitute “personal information” in terms of the
Privacy Act 1993. The person about whom this information and opinion are provided (the applicant)
is entitled to have access to this report under IPP6 and to seek correction of this report under IPP7.
Information or opinion provided in this report may be disclosed under IPP11 to the applicant and
members of the Selection Committee.
PLEASE RETURN THIS FORM AFTER COMPLETION TO THE APPLICANT WHO IS RESPONSIBLE
FOR ITS RETURN TO NORTHTEC ENQUIRIES & ENROLMENTS (UNLESS IT IS TO BE KEPT
CONFIDENTIAL). IF CONFIDENTIAL, PLEASE POST TO:
ENQUIRIES AND ENROLMENTS, PRIVATE BAG 9019, WHANGAREI, 0148
ADMINISTRATION ONLY:
RECEIVED: VIEWED:
28You can also read
