NERPSA Staff Study Progress & Practicum Placement Form

NERPSA Staff Study Progress & Practicum Placement Form
This form is for staff who are currently studying or planning to commence study. The information you provide helps NERPSA support your professional development and coordinate practicum placements in line with the National Quality Framework.

Please note that staff may complete one (1) required practicum placement at their primary place of work, with all placements managed in accordance with NERPSA’s Participation of Volunteers and Students Policy.
SECTION 1 — Staff Details
Full Name

First NameLast Name
Email
example@example.com
Primary Place of Work (NERPSA service)
Select the NERPSA service where you are primarily employed
Study Status
SECTION 2 — Course Information
Name of Course
e.g. Diploma of Early Childhood Education and Care
Name of Training Institution
e.g. TAFE, University, Registered Training Organisation (RTO)
Course Start Date

DayMonthYear
2 digit day, 2 digit month, 4 digit yearDate
Expected Course Completion Date

DayMonthYear
2 digit day, 2 digit month, 4 digit yearDate
Current Study Progress
e.g. percentage completed, units remaining, or write ‘Just starting’
Training Institution Contact Person
Name and email for placement or practicum agreements. Write ‘N/A’ if not yet known.
SECTION 3 — Practicum History & Requirements
Completed Practicum Placements
List service names, age ranges, dates and hours completed. Write ‘N/A’ if none completed.
Remaining / Upcoming Practicum Requirements
List required age groups, total hours, and any specific placement requirements. Write ‘N/A’ if not yet known.
Proposed Dates for Upcoming Practicum Placements
Provide indicative dates or write ‘N/A’ if not yet known.
Mentor / Supervisor Requirements
Does your training provider require a supervisor with a specific qualification (e.g. Bachelor‑qualified ECT)
SECTION 4 — Placement Planning & Logistics
Placement Preferences
If you are required to complete placements outside your primary place of work, indicate any preferred NERPSA services.
Travel Capacity
How far are you reasonably able to travel for a practicum placement?
Roster Impact Considerations
Are there any roster, hours or availability considerations NERPSA should be aware of?
Conflict of Interest Declaration
Do you have family members attending, employed at, or closely connected to any other NERPSA services? If yes, please provide details. Write ‘None’ if not applicable.
SECTION 5 — Privacy & Declaration
NERPSA collects this information to meet regulatory requirements, support professional development, and coordinate practicum placements. Information is stored securely and managed in accordance with NERPSA’s Privacy and Confidentiality obligations.
Declaration
Signature
Should be Empty:

NERPSA Staff Study Progress & Practicum Placement Form

SECTION 1 — Staff Details

SECTION 2 — Course Information

SECTION 3 — Practicum History & Requirements

SECTION 4 — Placement Planning & Logistics

SECTION 5 — Privacy & Declaration