Advanced Health Management Programme (AHMP)

Surname: *

Title: Mr Ms Miss Mrs Dr Prof CA ADV *

First Name: *

Preferred Name:

ID Number / Passport Nr: *

Job Title: *

List the regulatory bodies you are registered with:

Highest Professional Qualification: *

Highest Management Qualification: *

Postal Address: *

City: *

Postal Code: *

Physical Address: *

City: *

Code *

Telephone: *

Fax: *

Mobile: *

E-mail: *

Name of Organisation you work for: *

Website:

Business Address: *

City: *

Code *

How did you hear about this course? FPD Website Word of Mouth Electronic FPD Workshop Other *

In which province do you want to attend? Mpumalanga Western Cape Free State Northern Cape Limpopo North West Eastern Cape Kwa-Zulu Natal *

How long have you worked in the AIDS field? 0 - 2 years 2 - 5 years 5+ years *

How long have you worked in an AIDS managerial post? 0 - 2 years 2- 5 years 5+ years *

Do you have management responsibilities? Yes
No
*

Do you manage other managers? Yes
No
*

If yes, how many? *

How may people fall under your management in total including non managerial staff? *

ON WHAT MANAGEMENT LEVEL ARE YOU? Executive (e.g. Report to Parliament, Owners, Shareholders or to Board of directors, etc.) Senior (e.g. Report to CEO or to Secretary General, or to Rector or to Director General, etc.) Middle (e.g. Report to Dean, or to Director, or to Head of Department, etc.) Junior (e.g. Report to Head of Division, etc) Other *

Which section do you work in? Public Private NGO FBO Other *

*IF YOU ARE NOT IN A MANAGERIAL POSITION, BUT PLAY A LEADERSHIP ROLE IN THE AIDS RESPONSE, PLEASE EXPLAIN YOUR ROLE.

PLEASE DESCRIBE YOUR INVOLVEMENT IN HIV/AIDS AND THE BENEFIT TO THE ORGANIZATION OF YOUR ATTENDANCE OF THE PROGRAMME *

THE HEALTH SERVICES FACES MANY SOCIO-ECONOMIC, CULTURAL AND POLITICAL CHALLENGES. IDENTIFY ONE POLICY AREA OF PARTICULAR INTEREST TO YOU (I.E. IMMIGRATION, EDUCATION, HEALTH CARE, EMPLOYMENT, ETC.) *

SUMMARIZE 3 TO 4 IMPORTANT ASPECTS PERTAINING TO THIS POLICY AREA, THAT IMPACT THE HEALTH SERVICES *

DESCRIBE WHAT YOU BELIEVE NEEDS TO HAPPEN AT THE POLICY, PROGRAM AND/OR COMMUNITY LEVELS TO ADDRESS THE ISSUE APPLICANTS *

EXPLAIN WHAT CONTRIBUTION YOU HAVE MADE TO IMPROVING HEALTHCARE DELIVERY TO PLWHA OR ANY OTHER UNINSURED POPULATION. WE ARE LOOKING FOR EXAMPLES OF WHERE YOU HAVE EXPANDED SERVICES, IMPROVED QUALITY OR INTRODUCED NEW SERVICES. I DECLARE THAT THE INFORMATION STATED ON THIS APPLICATION FORM IS TRUE AND THAT ANY MISSING INFORMATION WILL RESULT IN IMMEDIATE CANCELLATION OF PROGRAMME ATTENDANCE UNDER THE SCHOLARSHIP PROGRAMME. SIGNATURE DATE APPLICANTS *

I DECLARE THAT THE INFORMATION STATED ON THIS APPLICATION FORM IS TRUE AND THAT ANY MISSING INFORMATION WILL RESULT IN IMMEDIATE CANCELLATION OF PROGRAMME ATTENDANCE UNDER THE SCHOLARSHIP PROGRAMME. *

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