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Self-Disclosure Form

As part of the application process, in addition to completing your Wintec application, for some of our programmes you are also required to complete this Self-Disclosure form. You can check the individual programme pages to see whether this is required or click here to check.

Click here to complete your Wintec application.

* Required Fields
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Are you an International student? *
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This programme provides you with the skills and knowledge required for jobs in areas like veterinary clinics and animal refuges.  In these workplaces you will have to care for, lift and hold animals.  You must also be able to work in aseptic conditions in a veterinary surgery.

Please indicate your pathway
Please indicate if you want to study face-to-face or online (the online option is only offered to candidates who already work in the industry for a minimum of 10 hours).

Teaching occurs in block teaching weeks held at the Hamilton City Campus. Between each of these teaching blocks students receive tutorials via the internet and with their clinical tutors in their chosen regional hub.

Tihei Mauri Ora Kaupapa (Bachelor of Nursing & Diploma in Enrolled Nursing) pathway

If you identify as a Māori or Pacific Islander you can choose to study in the Tihei Mauri Ora pathway - this option allows you to study in a culturally supportive environment.

Please indicate if you wish to be enrolled into the Tihei Mauri Ora pathway

Physical Ability

Working with animals can be physically challenging; in order to support you through your studies we need to be aware of any restraints that may impact your likelihood of success in the programme, or your ability to gain work. In a veterinary clinic, for example, you may be required to lift a 20 kg companion animal from the floor to a 1 metre high veterinary examination table.

Please answer the following questions providing as much detail as you can:

Are you able to lift weights up to 20kg?
Are you able to lift your arms above your head for at least 30 seconds? e.g. In order to clean cages
Are you able to hold and restrain an animal up to 45kg? e.g. For a medical procedure
Are you able to step up or over 0.5 metre height? e.g. Over a fence into a cage
Are you able to use fine motor skills? e.g. Use both hands on a keyboard to enter data, or hold and restrain an animal with one hand and perform a procedure with the other
Do you have or have you had any known medical condition that will affect your ability to work within an aseptic environment in a veterinary surgery? This includes any skin condition and/or history of dermatitis, eczema or psoriasis that may not allow frequent contact with water, soap, disinfectant and cleaning chemicals; or any condition causing open wounds.
Do you have any allergies to disinfectants commonly used in veterinary clinics?
I understand that if any false or deliberately misleading information is given, or any material fact suppressed my enrolment may be terminated.

The Centre for Health and Social Practice requires the information below to ensure you have the opportunity to disclose any factors that support your application for selection to the Bachelor of Physiotherapy programme.  This includes ensuring students are supported to succees in the programme and are safe to work with members of the public.

The Centre for Education and Foundation Pathways requires the information below to ensure you have the opportunity to disclose any barriers that may affect your ability to complete the programme. This includes ensuring students are supported to succeed in the programme and are safe to work with members of the public.

To support your application we also require a reference to support your personal statements and in particular your community engagement. A link to our online referee questionnaire is provided once you submit your Self Disclosure form – please provide this to your referee.

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Employment 3
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Employment 4
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Employment 5
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Employment 6
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Work Placement and Attendance

Students enrolled in the Primary Care Practice Assistance programme are required to be working (paid or voluntarily) for at least 12.5 hours per week in a primary care practice and hold a current first aid certificate.

Do you currently, or will you by the start of the programme, have a 12.5 hours per week placement?

Please provide details of your employer/placement below:

Students enrolled in the Bachelor of Teaching (Early Childhood Education) are required to be working (paid or voluntarily) for at least 12 hours per week in a licensed early childhood setting by the start of the programme.

Do you currently, or will you by the start of the programme, have a twelve hours per week placement?
Have you completed a police vetting check within the last 3 years as a requirement of your employment in an early childhood setting?

To complete the Bachelor of Teaching (Early Childhood Education) successfully there are a number of compulsory activities you will be required to participate in and attend each year. These include:

  • One Saturday workshop per year
  • One noho marae stay per year (3 days and 2 nights)
  • One Practicum per year (3 weeks in year one, 4 weeks in year two and 5 weeks in year three)
Is there anything that will prevent you from attending any of these activities?

Professional Registration Details

Please provide details of your professional registration below.

Have you received a letter from the Nursing Council of New Zealand outlining the study requirements to regain your practising certificate?
Are there any conditions on your practising certificate? eg do you need supervision to practise?
Is the name you are using to enrol at Wintec the same as the name on your practising certificate or registration?

Funding Your Study

To ensure we are able to process your enrolment correctly, please provide details of how you intend to fund your programme of study.

Is your study being funded, or partially funded, by Health Workforce New Zealand (HWNZ)?
Is your study being funded, or partially funded, by a scholarship?
Is your study being funded, or partially funded by your employer (not through HWNZ)?
Are you funding your study yourself eg through a StudyLink loan?

Employment Details

To enrol in this programme students are required to be working a minimum of 16 hours per week as a nurse or a midwife.

Please provide the name and contact details of your line manager, or the person supporting your application, who we can contact as a reference if required regarding your application

Module Selection

Please indicate below the module(s) you wish to enrol into – details of the modules can be found in our Postgraduate guide

If you’re not sure which modules best compliment your area of work, please tick unsure in the box below and we will contact you. (Students studying part-time usually take one module per semester.)

If you would like to discuss pathway options or modules you can also email the postgraduate team at pghsp@wintec.ac.nz

Semester 1

Unsure?

Semester 2

Unsure?

Police Check

At the start of the course all new students are required to undertake a Police check. A clean Criminal Convictions History from the Ministry of Justice which is six months old or less meets this requirement. Please bring a copy of this report on your first day - you can use this link to apply.

If you are a returning student who has studied with us in the last calendar year and you have previously supplied a criminal convictions report or undertaken a police check you can complete the following declaration instead.

I confirm my criminal conviction history has not changed in the last year since I last completed a police check.

Under the Health Practitioners Competence Assurance Act (HPCA Act) 2003, some criminal convictions may result in Midwifery Council of New Zealand refusing to allow an applicant to register as a midwife.

Under the Health Practitioners Competence Assurance Act (HPCA Act) 2003, some criminal convictions may result in the Physiotherapy Board of New Zealand refusing to allow an applicant to register as a physiotherapist.

Under the Health Practitioners Competence Assurance Act (HPCA Act) 2003, some criminal convictions may result in Nursing Council of New Zealand refusing to allow an applicant to register as a nurse.

You should be aware that some criminal convictions might prevent you from working in the early childhood education sector; some types of criminal conviction may also limit the ability to secure practical placements and therefore complete the programme.

You should be aware that some criminal convictions might prevent you from practicing as a primary care practice assistant. 

You should be aware that some criminal convictions might prevent you from practicing as a Counsellor; some types of criminal conviction may also limit the ability to secure practicum placements and therefore complete the programme.

 

Team Manager ECE
Email: educationandfoundation@wintec.ac.nz
Postal Address: Freepost 566, Attention Team Manager ECE, Centre for Education and Foundation Pathways, Wintec, Private Bag 3036, Hamilton 3240
(please mark as private and confidential)

Head of Nursing
Email: chasp.applications@wintec.ac.nz
Postal Address: Freepost 566, Attention Head of Nursing, CHASP, Wintec, Private Bag 3036, Hamilton 3240
(please mark as private and confidential)

Head of Midwifery
Email: chasp.applications@wintec.ac.nz
Postal Address: Freepost 566, Attention Head of Midwifery, CHASP, Wintec, Private Bag 3036, Hamilton 3240
(Please mark as private and confidential)

Head of Physiotherapy
Email: chasp.applications@wintec.ac.nz
Postal Address: Freepost 566, Attention Head of Physiotherapy, CHASP, Wintec, Private Bag 3036, Hamilton 3240
(Please mark as private and confidential)

Primary Care Practice Assistant Team Manager – Helen Nielsen
Email: Helen.Nielsen@wintec.ac.nz
Postal Address: Freepost 566, Helen Nielsen, Team Manager, CHASP, Wintec, Private Bag 3036, Hamilton 3240
(Please mark as private and confidential)

Postgraduate Team Manager – Helen Nielsen
Email: Helen.Nielsen@wintec.ac.nz
Postal Address: Freepost 566, Helen Nielsen, CHASP, Wintec, Private Bag 3036, Hamilton 3240
(Please mark as private and confidential)

Team Manager ECE
Email: educationandfoundation@wintec.ac.nz
Postal Address: Freepost 566, Attention Team Manager ECE, Centre for Education and Foundation Pathways, Wintec, Private Bag 3036, Hamilton 3240
(please mark as private and confidential)

Head of Nursing
Email: chasp.applications@wintec.ac.nz
Postal Address: Freepost 566, Attention Head of Nursing, CHASP, Wintec, Private Bag 3036, Hamilton 3240
(please mark as private and confidential)

Head of Midwifery
Email: chasp.applications@wintec.ac.nz
Postal Address: Freepost 566, Attention Head of Midwifery, CHASP, Wintec, Private Bag 3036, Hamilton 3240
(Please mark as private and confidential)

Head of Physiotherapy
Email: chasp.applications@wintec.ac.nz
Postal Address: Freepost 566, Attention Head of Physiotherapy, CHASP, Wintec, Private Bag 3036, Hamilton 3240
(Please mark as private and confidential)

Primary Care Practice Assistant Team Manager – Helen Nielsen
Email: Helen.Nielsen@wintec.ac.nz
Postal Address: Freepost 566, Helen Nielsen, Team Manager, CHASP, Wintec, Private Bag 3036, Hamilton 3240
(Please mark as private and confidential)

Postgraduate Team Manager – Helen Nielsen
Email: Helen.Nielsen@wintec.ac.nz
Postal Address: Freepost 566, Helen Nielsen, CHASP, Wintec, Private Bag 3036, Hamilton 3240
(Please mark as private and confidential)

I agree to discuss my convictions in an interview with the Team Manager / Programme Co-ordinator. I understand that my offending may impact on my ability to participate in a workplace experience and therefore my ability to complete the programme.

Team Manager ECE
Email: educationandfoundation@wintec.ac.nz
Postal Address: Freepost 566, Attention Team Manager ECE, Centre for Education and Foundation Pathways, Wintec, Private Bag 3036, Hamilton 3240
(please mark as private and confidential)

Head of Nursing
Email: chasp.applications@wintec.ac.nz
Postal Address: Freepost 566, Attention Head of Nursing, CHASP, Wintec, Private Bag 3036, Hamilton 3240
(please mark as private and confidential)

Postgraduate Team Manager – Helen Nielsen
Email: Helen.Nielsen@wintec.ac.nz
Postal Address: Freepost 566, Helen Nielsen, CHASP, Wintec, Private Bag 3036, Hamilton 3240
(Please mark as private and confidential)

Primary Care Practice Assistant Team Manager – Helen Nielsen
Email: Helen.Nielsen@wintec.ac.nz
Postal Address: Freepost 566, Helen Nielsen, Team Manager, CHASP, Wintec, Private Bag 3036, Hamilton 3240
(Please mark as private and confidential)

Head of Physiotherapy
Email: chasp.applications@wintec.ac.nz
Postal Address: Freepost 566, Attention Head of Physiotherapy, CHASP, Wintec, Private Bag 3036, Hamilton 3240
(Please mark as private and confidential)

Head of Midwifery
Email: chasp.applications@wintec.ac.nz
Postal Address: Freepost 566, Attention Head of Midwifery, CHASP, Wintec, Private Bag 3036, Hamilton 3240
(Please mark as private and confidential)

Do you have or have you had any known physical or mental health condition that might impact on your ability to engage in learning and meet academic commitments, or your ability to engage with people from a wide range of backgrounds during your programme?
Do you have or have you had any known medical condition(s) (physical or mental) that will affect your ability to work within a clinical environment? This includes any skin condition and/or history of dermatitis, eczema or psoriasis that may not allow frequent contact with water, soap, disinfectant and cleaning chemicals

Head of Nursing
Email: chasp.applications@wintec.ac.nz
Postal Address: Freepost 566, Attention Head of Nursing, CHASP, Wintec, Private Bag 3036, Hamilton 3240
(please mark as private and confidential)

Postgraduate Team Manager – Helen Nielsen
Email: Helen.Nielsen@wintec.ac.nz
Postal Address: Freepost 566, Helen Nielsen, Team Manager, CHASP, Wintec, Private Bag 3036, Hamilton 3240
(Please mark as private and confidential)

Primary Care Practice Assistant Team Manager – Helen Nielsen
Email: Helen.Nielsen@wintec.ac.nz
Postal Address: Freepost 566, Helen Nielsen, Team Manager, CHASP, Wintec, Private Bag 3036, Hamilton 3240
(Please mark as private and confidential)

Head of Nursing
Email: chasp.applications@wintec.ac.nz
Postal Address: Freepost 566, Attention Head of Nursing, CHASP, Wintec, Private Bag 3036, Hamilton 3240
(please mark as private and confidential)

Postgraduate Team Manager – Helen Nielsen
Email: Helen.Nielsen@wintec.ac.nz
Postal Address: Freepost 566, Helen Nielsen, Team Manager, CHASP, Wintec, Private Bag 3036, Hamilton 3240
(Please mark as private and confidential)

Primary Care Practice Assistant Team Manager – Helen Nielsen
Email: Helen.Nielsen@wintec.ac.nz
Postal Address: Freepost 566, Helen Nielsen, Team Manager, CHASP, Wintec, Private Bag 3036, Hamilton 3240
(Please mark as private and confidential)

I understand that if any issues arise that impair my ability to work consistently in my studies or during placement, I may be asked to withdraw from study. I understand the Team Manager / Programme Co-ordinator will involve me in all processes about any course of action and subsequent outcomes. Note: Significant support is available to students of Wintec, we anticipate that these avenues of support will have been exhausted prior to having to engage in any process that would see you asked to withdraw from the programme.
I understand that if any issues arise that impair my ability to work consistently in my studies or during work based learning, I may be asked to withdraw from study for a period of time. I understand the Team Manager will involve me in all processes about any course of action and subsequent outcomes. I understand that I may be required to provide medical clearance to re-enter the programme.
I understand that the Centre for Education and Foundation Pathways requires the above information to protect the public and staff in organisations where I may be placed for practical experience.
Have you ever been declined registration by the Physiotherapy Board of New Zealand?
Have you ever been declined registration by Nursing Council of New Zealand?
Have you ever been declined registration by Midwifery Council of New Zealand?
Have you ever been declined registration by the Education Council of Aotearoa New Zealand?
Have you ever been disciplined by a regulatory authority e.g. The Education Council of Aotearoa New Zealand?
I understand that the Centre for Education and Foundation Pathways requires the above information in order to: Protect students, public and staff in organisations where I may be placed for practical experience. I understand that failure to disclose relevant information at any time prior to or during my programme of study will lead to disciplinary action which may result in dismissal from the programme.
To progress your application for the Bachelor of Teaching (Early Childhood Education) you are also required to complete the online Additional Information Form. Please indicate below if you have completed this yet. It’s fine if you haven’t a link to the form will be provided once you submit your Self-Declaration.
Have you ever been disciplined by a regulatory authority eg Nursing Council, Education Council?
Have you ever been or are you currently subject to any investigation/complaint and/or disciplinary action by any education institute, health authority, government agency and any other organisation in New Zealand or overseas?
Have you ever been disciplined or dismissed by an employer?
Have you ever previously been enrolled in a nursing programme or any other degree level study?
Have you ever previously been enrolled in a midwifery programme or any other degree level study?
Have you ever previously been enrolled in a physiotherapy programme or any other degree level study?
I understand that the Centre for Health and Social Practice requires the above information in order to: Protect service users and tangata whaiora, public and staff in hospitals or other organisations where I may be placed for practical experience and to ensure the integrity of the Centre’s recommendation to the Midwifery Council of New Zealand made under Section 16 of the Health Practitioners Competence Assurance Act 2003
I understand that the Centre for Health and Social Practice requires the above information in order to: Protect service users and tangata whaiora, public and staff in hospitals or other organisations where I may be placed for practical experience.
I understand that the Centre for Health and Social Practice requires the above information in order to: Protect service users and tangata whaiora, public and staff in hospitals or other organisations where I may be placed for practical experience and to ensure the integrity of the Centre’s recommendation to the Nursing Council of New Zealand made under Section 16 of the Health Practitioners Competence Assurance Act 2003
Do you hold a current first aid certificate?
If No, I agree to attain a first aid certificate prior to undertaking any clinical practice module in the programme.

Referee Details

Please provide the contact details of a person who is willing to act as a referee for you – this is likely to be a past or current employer or a tutor or teacher who has known you for at least two years (not a family member or friend). We will only contact your referee if we need further information to assess your application.

Practice Placements and Transportation

If you currently hold a restricted license, you will need to identify alternative transport arrangements before you go out on clinical placements, which may require you to attend after 10pm.

You should be aware that it is likely you will need unrestricted access to a reliable vehicle by the time you are rostered for your first clinical placement.

As part of your programme you will be required to undertake clinical placements which will require you having access to reliable transport to both local and rural clinical placements for both day and night shifts. This is important to consider if you currently hold only a restricted license.

I understand that this programme requires clinical placement. I confirm that I understand that I am responsibile for managing travel and accomodation to support the completion of the programme.
Do you hold a full driver's licence?

Self-Declaration

I understand that if any false or deliberately misleading information is given, or any material fact suppressed, my enrolment may not be accepted.
I declare that to the best of my knowledge the answers I have provided are correct. I have not withheld any information that could have a material bearing on my enrolment.

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