APPLICATION FORM AND IMPORTANT INFORMATION FOR THE2019 ROWAN NICKS PACIFIC ISLANDS SCHOLARSHIP

INSTRUCTIONS

• Read the following information and make sure you meet the eligibility criteria• Complete ALL boxes in the Application Form• Complete the Application Form in English• Attach a copy of your current Curriculum Vitae in accordance to the provided template• Attach a certified copy of your basic medical degree and English translation• Attach a certified copy of your post-graduate qualification and English translation• Attach a certified copy of your current Medical Registration and English translation• Attach a certified copy of either your IELTS, OET, PTE Academic or TOEFL iBT test results (see appendix 1)• Attach a copy of the completed Application Checklist• Send an email with a scanned, signed, copy of this form and all attachments to

international.scholarships@surgeons.org OR a signed, hard copy of this form and all attachments to:

Secretariat, Global Health Scholarships Committee Royal Australasian College of Surgeons College of Surgeons’ Gardens250 – 290 Spring StreetEast Melbourne, Victoria 3002AUSTRALIA

Applications must be submitted by no later than 5pm Australian Eastern Standard Time on Friday, 4 May 2018

1

ABOUT THE ROWAN NICKS PACIFIC ISLANDS SCHOLARSHIP

The Royal Australasian College of Surgeons (the College) offers the Rowan Nicks Pacific Islands Scholarship each year. The Rowan Nicks Scholarships and Fellowships are the most prestigious of the College’s international awards and are directed at qualified surgeons who have the potential to be leaders in their countries. The Rowan Nicks Pacific Islands Scholarship is specifically designed for surgeons from Pacific Islands in the South West Pacific Region.

The Scholarship provides opportunities for surgeons who demonstrate the potential to become leaders in their country of origin, and/or to surgeons who will return to supply a much-needed service in a particular surgical discipline. The intention is to develop their skills to enable them to:

• Manage a department• Become competent in the teaching of others• Gain experience in clinical research and the applications of modern surgical technology, and;• Obtain further advanced exposure in general or specialist surgery

Applicants may wish to apply for short-term attachments (i.e. 3 months) to focus on clinical administration, management, organisation of training, structuring a clinical service. These attachments will emphasise leadership and organisational competencies, and will not require applicants to gain medical registration with the Medical Board of Australia. Applicants applying under this stream will be subject to the same selection criteria at those pursuing a clinical attachment, and will be required to demonstrate a minimum IELTS (academic module) score of 7 in each category or the equivalent.

Whilst the foregoing is the ideal, the circumstances and specific needs of potential candidates and their countries could be somewhat different and this should not preclude such persons from applying for the Scholarship. Selection is primarily based on merit, however, applications providing a valuable service in remote areas, without opportunities for institutional support or educational facilities will be given special consideration.

The Rowan Nicks Scholarships are not just personal awards; the orientation is to “teach the teacher to teach others” and the recipient must come with a sense of responsibility to the needs of his/her country. The intention is that the scholar will share the skills and expertise with their colleagues upon return to their home country, thereby increasing the local capacity to deliver improved surgical and medical care to the local community.

Applications should demonstrate:

• A high calibre in surgical ability, ethical integrity, and qualities of leadership• A commitment to teach and promulgate high standards in the development of surgery in their country

The Scholarship is usually tenable in a major hospital (or hospitals) in Australia or New Zealand, and will be awarded for a period of up to 12 months. Candidates may apply to undertake their Scholarship in a country other than Australia or New Zealand on the provision that a supervisor has been identified and agrees to the position, and that the language requirements for medical registration in that country can be met.

The Scholarship will provide funds for return economy class travelling expenses between the home country and hospital attachment for the Scholar as well as support to attend the Royal Australasian College of Surgeons’ Annual Scientific Congress (ASC) or equivalent conference (if in Australia or New Zealand at the relevant time). Funds to attend the ASC will be supplied to cover the cost of registration, travel and accommodation for the Scholar only. The Scholarship will provide a living allowance of up to AUD$40,000 for a 12-month attachment plus up to $10,000 to cover administrative and settling-in expenses.

CONDITIONS OF THE ROWAN NICKS PACIFIC ISLANDS SCHOLARSHIP

2

The Scholarship does not cover any costs associated with the Scholar’s family members. Scholars are welcome to be accompanied by family members at their own cost.

The Scholar will be encouraged to visit other appropriate institutions in Australia and New Zealand or appropriate other country during their attachment. Funds required for travel for this purpose will be considered on an individual basis.

The Scholar must provide a progress report half-way through a 12-month Scholarship and also at the conclusion of the Scholarship. The final report should be no less than 1000 words in length. When the Scholarship is for 6-months or less, one report only will be required.

3

Applicants must:

1. Be a citizen of the country from which the application is made2. Be between the ages of 25-45 years inclusive on the closing date of applications.3. Have completed post-graduate training in surgery, and hold his/her country’s post-graduate

qualification in surgery, or have completed the Master of Medicine (MMed) examination. This isessential.

4. Be fluent in the English language. Applicants must provide evidence that they meet the Englishlanguage requirement for registration with the Medical Board of Australia or Medical Councilof New Zealand. See Appendix 1 for details of the minimum requirements.

5. Provide the names and full contact details of the referees as outlined in the application form. Failureto include the names of referees may adversely affect the application in the selection process

6. Guarantee to return to his/her home country on completion of the Scholarship.

ELIGIBILITY FOR THE ROWAN NICKS PACIFIC ISLANDS SCHOLARSHIP

• Cook Islands• Fiji• Kiribati• Federated States of Micronesia• Marshall Islands• Nauru

• Papua New Guinea• Samoa• Solomon Islands• Tonga• Tuvalu• Vanuatu

Applications for the 2019 Pacific Islands Scholarship are open to qualified surgeons from*:

* Applicants from other countries outside the above list considering applying for the 2019 scholarship must contact the Secretariat before the closing date to confirm whether they are eligible to apply.

Referees and Sponsorship:

Following the closing date for applications the College will contact the persons listed to obtain written references. Persons must not be listed more than once in a single application form. Please do not supply written references with your application form. The references the College will be seeking are in a standard format and additional references will not be considered.

The value of the Scholarship may be reduced if the Scholar will receive a salary or funding from another source while undertaking the Scholarship program. Candidates are obligated to declare to the Committee any additional funding obtained or applied for at the time of application, after the submission of the application and at any stage during the selection process and during the tenure of the Scholarship.

PROFESSIONAL REFEREES - These are 2 referees such as surgical colleagues or supervisors who are able to comment on you in a professional capacity. To ensure that the College is able to collect a comprehensive reference from the referees, please include referees who are able to comment on areas of your performance such as your experience, reputation and surgical skills. It is compulsory that full contact details for 2 referees be supplied.

HOSPITAL OR UNIVERSITY SPONSOR - It is compulsory that you supply the name and contact details of a sponsor from your Hospital or University. Such a person would include the Head of the Department, Hospital or University, or the Ministry of Health. A supervisor or colleague is NOT an appropriate sponsor. This person will be asked to comment on areas of your professional standing in your community, without necessarily being familiar with your surgical skills. The latter will have been addressed by your referees.

ADDITIONAL REFEREE - You may supply the name and contact details of an Australian or New Zealand referee with whom you have worked and who is able to comment on you in a professional capacity. It is NOT a compulsory requirement to have an Australian or New Zealand referee.

4

For each of these sponsors or referees the following guidelines must be met:

Applicants will only be considered if they meet the eligibility requirements of the Scholarship and have completed the Application Form in its entirety following the instructions supplied. Applications must be received by 5pm AEST on Friday, 4 May 2018 at the following address:

Secretariat, Global Health Scholarships Committee Royal Australasian College of Surgeons College of Surgeons’ Gardens250-290 Spring StreetEast Melbourne, Victoria 3002Australia

Telephone: + 61 3 9249 1211Facsimile: +61 3 9276 7431Email: international.scholarships@surgeons.org

Applications received after this date will not be considered.

The Global Health Scholarships Committee will undertake the review and selection of the Scholars. The Committee will primarily consider the potential of the applicant to become a leader in the country of origin, and/or to supply a much-needed service in a particular surgical discipline. The Committee must be convinced that the applicant is of high calibre in surgical ability, ethical integrity, and qualities of leadership, and the references collected by the College from the referees support the applicant as one who will teach and promulgate high standards in the development of surgical experience in their country.

The Selection Committee will make the final recommendations to the College Council in November 2018. Once an official decision is made all applicants will be officially notified of the outcome via email by 31 December 2018. The view of the Council will be final.

SELECTION PROCEDURE FOR THE ROWAN NICKS SCHOLARSHIP

APPLICATION FORM FOR THE 2019 ROWAN NICKS PACIFIC ISLANDS SCHOLARSHIP

1. Personal Details

Title

Family Name (as shown on Birth Certificate)

Married Name (if different from name on Birth Certificate)

Given Names (as shown on Birth Certificate)

Country of Citizenship

Gender Male Female

Date of Birth(must be between 25-45 years by closing date of applications. Proof of age may be requested)

2. Contact Details

Current Residential Address:

Address Line 1

Address Line 2

Address Line 3

Town/City Postal Code (if any)

State/Province

Country

Home Phone number Work Phone number

Mobile number

Email6

Mailing Address (only if different from your current residential address):

Address Line 1

Address Line 2

Address Line 3

Town/City Postal Code (if any)

State/Province

Country

3. English Language Proficiency

Are you fluent in the English Language? Yes No(Note: Applicants will be required to meet the English Language Requirement for medical registration in Australia or New Zealand)

Have you taken an IELTS test? Yes No

Date test taken:

Test Results:

Listening Reading Writing Speaking Overall Band Score

Details of any English language training currently being undertaken:

4. Conferences Attended

5. Papers Presented

7

6. Current Hospital/Institution of Employment

Institution Name:

Contact name for enquiries regarding institution/hospital

Telephone

Email

Address Line 1

Address Line 2

Town/City Postal Code (if any)

State/Province

Country

Type of InstitutionPlease select one option only

Government

Military

Private (philanthropic)

Private (non-philanthropic)

Other (please describe)

Please provide a statement describing your current hospital/institution of employment; including its history, funding source/s, mission and objectives. In particular, if your institution has strong philanthropic motivators, please outline these in detail:

8

7. Proposed Program Activity

a. What program or course of study would you pursue using this Scholarship? (150-300 words suggested)

b. What are your specific skills and knowledge objectives for your proposed program or course of study?(Please list at least 5)

c. If you are offered the Scholarship, what is your preferred location for your placement?

Australia New Zealand Other (Please Specify):

d. For what length of time would you like to undertake this Scholarship?

3 months 6 months 9 months 12 months

8. Supporting Statements

a. What is your motivation for applying for this Scholarship? (100-150 words suggested)

9

b. If successful in obtaining this Scholarship, what contributions do you plan to make to improve healthoutcomes in your home country after completing your attachment? How do you plan to meet theseobjectives? (200-400 words suggested).

c. If successful in obtaining this Scholarship, how do you plan to share the skills and knowledge you gainin Australasia with your colleagues in your home country after completion of your attachment? (150-300 words suggested).

d. How would this experience improve your leadership potential? (100-150 words suggested)

e. Is there anything else you would like to add in support of your application for this Scholarship?

10

9. Referees and Sponsorship

Please provide the names and full contact details of 2 referees who are able to comment on you in a professional capacity.

Reference One

Title

Name

Position

Institution

Address Line 1

Address Line 2

Town/City Postal Code (if any)

State/Province

Country

Telephone

Email

Reference Two

Title

Name

Position

Institution

Address Line 1

Address Line 2

Town/City Postal Code (if any)

State/Province

Country

Telephone

Email

11

Additional Referee (Optional)

Please provide the details of an Australian or New Zealand Fellow with whom you have worked in a professional capacity. (Please note this is optional. It is NOT necessary to list an Australian or New Zealand reference).

Title

Name

Position

Institution

Address Line 1

Address Line 2

Town/City Postal Code (if any)

State/Province

Country

Telephone

Email

Hospital or University Sponsor

Please provide the name and details of a Hospital or University referee such as the Head of the Hospital or University, Head of your Department or the Ministry of Health. This person should be a sponsor and NOT a referee.

Title

Name

Position

Institution

Address Line 1

Address Line 2

Town/City Postal Code (if any)

State/Province

Country

Telephone

Email

12

Declaration

I confirm that the information supplied within at the time of application is correct, and acknowledge that I am obligated to advise the Global Health Scholarships Committee of the Royal Australasian College of Surgeons (the College) of any changes to the information supplied within this application at any stage during the application period, selection process or while undertaking the Scholarship (if successful).

I have read the Conditions of the Rowan Nicks Scholarship of the College and agree to abide by these conditions.

I acknowledge that I am obligated to declare any additional funding obtained or applied for at the time of application, after the submission of the application and at any stage during the selection process and after the commencement of the Scholarship (if successful).

I note that the amount of the Scholarship awarded will be at the discretion of the Committee and may be reduced if I accept a salary or payment from my host institution or if I am successful in raising additional funds at any stage before or after the commencement of the Scholarship.

I consent to the information on this form being used and disclosed as stated.

Signature Date

This application form, completed in its entirety, must reach the Global Health Scholarships Committee Secretariat via post mail, fax or email by Friday 4 May 2018.

13

ROWAN NICKS PACIFIC ISLANDS SCHOLARSHIP APPLICATION CHECKLIST

The below is required for your application. Please make sure you have attached all required documents in their correct form to this application. Please do not send any other documents unless requested.

Certified copy of basic qualification – English translation must be attached

Certified copy of post-graduate qualification – English translation must be attached

Certified copy of current Medical Registration – English translation must be attached

Copy of either your IELTS, OET, PTE Academic or TOEFL iBT test results (see appendix 1)

Full contact details of 2 professional referees

Full contact details of 1 sponsor from your Hospital or University

Full contact details of sponsor in Australia or New Zealand (optional)

Current CV formatted in accordance with the provided template

14

Appendix 1

English Language Requirement

Applicants for the Rowan Nicks Pacific Islands Scholarship must provide evidence that they meet the English language requirement for registration with the Medical Board of Australia or Medical Council of New Zealand in order to be eligible for a 2019 Rowan Nicks Scholarship.

The following tests of English language skills are accepted by the Boards for the purpose of meeting the requirement.

For registration in Australia: a) The IELTS examination (academic module);b) The OET examination;c) The PTE Academic examination;d) The TOEFL iBT examination

Current as of July 2010, all applicants to the Medical Board of Australia MUST be able to demonstrate English language skills at IELTS (academic module) level 7 or the equivalent.

Please refer to the Medical Board of Australia: “English Language Skills Registration Standard” for more information about the minimum requirements: http://www.medicalboard.gov.au/Registration-Standards.aspx

For registration in New Zealand: a) The IELTS examination (academic module);

c) NZREX

Current as of October 2010, all applicants to the Medical Council of New Zealand MUST be able to demonstrate English language skills at IELTS (academic module) level 7.5 for speaking and listening, and level 7 for writing and reading or the equivalent.

Please refer to the Medical Council of New Zealand: “Policy on English Language Requirements” for more information about the minimum requirements: http://www.mcnz.org.nz/get-registered/how-to-register/english-language-requirements/

Notes: Results from any of the abovementioned English language examinations must be obtained in one sitting, or a maximum of two test sittings in a 6-month period.

Please refer to the IELTS website for further information and local test dates in your country: http://www.ielts.org

The examination fee is to be borne by the applicant. If you are unsure whether you meet the English Language eligibility criteria please contact the Secretariat prior to the closing date for further information.

b) The OET examination;

Appendix 2

Rowan Nicks International and Pacific Islands Scholarship Mark Sheet

ROYAL AUSTRALASIAN COLLEGE OF SURGEONS ROWAN NICKS SCHOLARSHIP 2019

MARK SHEET

Candidate:

Marker:

Total Mark (out of 45): ________ (sum of parts 2 and 3)

1 – Eligibility (Secretariat to Complete)

1. Appropriately Qualified - the applicant has completed relevant post graduate training inSurgery Yes / No

2. Sponsorship - from Head of Department / Ministry of Health confirming support of theProgram Yes / No

3. References received, positively describing the applicant's surgical competence, ability andcharacter Yes / No

4. English Language - Meets English Language requirement for Medical Registration inAustralia or New Zealand. Yes / No

2 – The Application

1. Experience in surgical discipline. /10

2. Academic attainment in addition to stipulated higher degree, eg: PhD, substantial number ofpapers presented etc. /5

3. Definition of objectives to promote surgery in home country. /5

4. Demonstration of leadership potential / contribution to the wider community. /10

3 – Appropriateness of Candidate

1. Appropriateness of proposed program to the needs of the home country / Value of proposedprogram to home country. /5

2. Match of the candidate to the objectives of the program & Deliverability of the proposedprogram (ie. has the candidate got the capacity to succeed). /5

3. OVERALL appropriateness including impression of applicant's ability to become a leader.

Weigh up the balance of qualifications, training experience and referee reports in light of the following identifiable criteria:

• Age of candidate in relation to opportunities• Previous opportunities already enjoyed (e.g. travel, courses etc.) / Conversely, lack of

opportunities because of impoverished state of the country, geographic site ofpractice, political and professional pressures

• Status and leadership positions already achieved determining placement andexperience.

• A realistic assessment by the candidate of the priority surgical needs of the country• The vision, enthusiasm and suitability of the candidate to meet those needs.• Reference from an Australasian Fellow who knows and has worked with the applicant.

/5

This Curriculum Vitae is true and correct as at ___________ _____________________ (Date) (Signed)

Curriculum Vitae Template

Personal Information

Name:

Address:

Phone:

Email:

Qualifications Obtained

Qualification- YYYY Name of Institution

Qualification- YYYY Name of Institution

Bridging Programs / Qualifying Examinations (Internship)

Position Title From: DD/MM/YYYY to DD/MM/YYYY Name of Facility Address: Result:

Clinical / Procedural Skills

-Competent (or observed) [describe skill] -Competent (or observed) [describe skill] -Competent (or observed) [describe skill]

Work / Practice History

Position Title From: DD/MM/YYYY to DD/MM/YYYY Name of Facility Address: Telephone: Responsibilities: List responsibilities

Full time or part time (hours worked per week)

Position Title From: DD/MM/YYYY to DD/MM/YYYY Name of Facility Address: Telephone: Responsibilities: List responsibilities

Full time or part time (hours worked per week)

This Curriculum Vitae is true and correct as at ___________ _____________________ (Date) (Signed)

Internship and Observership

Position Title From: DD/MM/YYYY to DD/MM/YYYY Name of Facility Address: Result:

Gaps in Work / Practice History There are no gaps in my practicing history except for recreational purposes or transfer of leave.

Please explain any gaps that exceed 3 months in duration.

Registration History

Current Registration Details From: YYYY to YYYY Registration Number:

Previous Registration Details From: YYYY to YYYY Registration Number:

I have not been previously registered to or am awaiting consideration from any other jurisdictions.

References and Publications

If applicable