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University of Tasmania Visiting Fellowships and Visiting Scholarships Program – Nomination Form Visit Classification Visiting Scholarship Visiting Fellowship Please provide below a rationale as to why this level of classification is being sought rather than the scholar level. Nominee’s Details (required for Human Resources purposes) Title: Given Names: Family Name: Postal Address: Email Address: Name of Home Institution: Home Institute Address: Current Position: Date of Birth: ………….……. (day)/ ………….……. (month)/ ………….……. (year) Emergency Contact Name: Contact Number: Relationship to Nominee: Citizenship: Type of Visa currently held/Type of Visa required for visit Please refer to the Procedure regarding Work Visas. International visitors will require a visa. It is the Visiting Fellow’s or Visiting Scholar's responsibility to obtain an appropriate visa. Other persons travelling with the Nominee: Please detail name(s) and relationship to nominee Details of Proposed Visit (nominee must have confirmed availability) Proposed Arrival Date Proposed End Date Duration of UTAS visit University of Tasmania: Visiting Fellowship and Visiting Scholarships Program – Nomination 1

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University of TasmaniaVisiting Fellowships and Visiting Scholarships Program – Nomination Form

Visit Classification

Visiting Scholarship Visiting FellowshipPlease provide below a rationale as to why this level of classification is being sought rather than the scholar level.

Nominee’s Details (required for Human Resources purposes)

Title: Given Names:

Family Name:

Postal Address:

Email Address:

Name of Home Institution: Home Institute Address:

Current Position:

Date of Birth:………….……. (day)/ ………….……. (month)/ ………….……. (year)

Emergency Contact Name: Contact Number:Relationship to Nominee:Citizenship:

Type of Visa currently held/Type of Visa required for visitPlease refer to the Procedure regarding Work Visas. International visitors will require a visa. It is the Visiting Fellow’s or Visiting Scholar's responsibility to obtain an appropriate visa.Other persons travelling with the Nominee:Please detail name(s) and relationship to nominee

Details of Proposed Visit (nominee must have confirmed availability)Proposed Arrival Date

Proposed End Date

Duration of UTAS visit

Sponsoring Organisational Unit(s)

Sponsoring Staff Member(s)

Organisational Unit Administrative Contact

University of Tasmania: Visiting Fellowship and Visiting Scholarships Program – Nomination 1

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University of TasmaniaVisiting Fellowships and Visiting Scholarships Program – Nomination Form

Consultation undertaken with colleaguesPlease detail below the extent of consultation, with whom, details of preliminary discussions, level of interest etc

Existing collaboration/connections between UTAS and the nominee Please detail below the extent of collaboration/connections.

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University of TasmaniaVisiting Fellowships and Visiting Scholarships Program – Nomination Form

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University of TasmaniaVisiting Fellowships and Visiting Scholarships Program – Nomination Form

Proposed Program of WorkFor some visitors, this work will be in the areas of research and research leadership only; others will participate in teaching programs and others in the delivery of public lectures, seminars and so on. Some visitors will negotiate a mixture of activities. Potential areas of work might include:

Collaborative research with UTAS staff Delivery of research papers to UTAS staff and students

Postgraduate thesis supervision and mentoring

Postgraduate coursework guest lecturing

Undergraduate coursework guest lecturing Public lectures Workshops with staff, students, and/or

community members Short course and summer school teaching

Proposed program of work Intended outcomes of the visit(insert text here) (insert text here)

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University of TasmaniaVisiting Fellowships and Visiting Scholarships Program – Nomination Form

Budget Template

Personal contribution (by visitor)

Sponsor contribution (research accounts)

Please advise research account codeOrganisational Unit contribution*Nominations that include co-funding are encouraged

Amount requested from Visiting Fellows/Scholars Funding Program

Total Projected Income

Projected Expenditure Calculations/Comments $ Amount

Airfares

Accommodation

Living allowance

Event costs

Other sundry items

Total Projected Expenditure

Additional Comments:

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University of TasmaniaVisiting Fellowships and Visiting Scholarships Program – Nomination Form

Resource RequirementsUse of University/Faculty/School Resources Please tick one or more as appropriate:‐☐ Minimal – building and/internet /library access only ☐ Regular – Office space only

☐ Regular – Office and High Risk Activity ☐ Other_____________________________

RISK ASSESSMENTLow Risk Activities Please tick

activity WHS Induction Requirement

Desk based, office based/classroom based activities with no high risk activities. If you are not sure, please check with your WHS Advisor.

Local Area Induction required on commencement

Supervision of Postgraduate students? Local Area Induction (may include Research Supervision Training by ORS on commencement)

High Risk Activities Please tick activity

WHS Induction Requirement

Laboratory/workshop/studio Local Area High Risk Induction

Field work Local Area High Risk Induction

Boating/Diving Local Area High Risk Induction

Activities involving driving, machinery or plant operation

Local Area High Risk Induction

Use of Chemicals, hazardous materials etc. Local Area High Risk Induction

Biosafety / Animal Handling Local Area High Risk Induction

Other (please detail) Local Area High Risk Induction

If from the above assessment, the activities are deemed greater than low risk, a formal risk assessment is required to be undertaken before commencement and in accordance with the University’s Risk Management Policy and Matrix and include appropriate risk controls to eliminate or minimise the risk so far as is reasonably practicable. Further information about WHS Induction and Training can be found here.

Please read and note the Work Health and Safety Information in the next section.

1. MEDICAL DISCLOSUREGiven the description of the contribution being made under this appointment Yes No• do you have a pre-existing medical condition or injury that would preclude you from ☐ ☐carrying out some or all of the duties of the position?

• are you taking any medication that could affect your health and safety or that of others, ☐ ☐whilst undertaking this appointment?

If YES, please provide details of the condition: _________________________________________________________________Approach your nominator to undertake a risk assessment to identify if there are reasonably practical controls available to the University to manage the identified risks to an acceptable level.

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University of TasmaniaVisiting Fellowships and Visiting Scholarships Program – Nomination Form

(Seek WHS Advisor support if required)

Is specialist medical or insurance advice required? Yes ☐ No ☐

Comment: _____________________________________________________

2. NOMINEE DECLARATIONI acknowledge that I have read and understand this document in relation to work in authorised activities on behalf of the University of Tasmania. I undertake to advise the Organisational Unit Head should circumstances change during my appointment that would alter the responses provided above.I have completed the sections of the document relevant to me and I declare that to the best of my knowledge the information given by me is complete and true.

Visitors are required to possess a Working with Children Registration if they undertake work in which they are in contact with children unless they are eligible for an exemption. Please review the University of Tasmania’s Working with Children Policy and Procedure and apply here if applicable (See Section 3, 3.1 of the Policy).

Signature of Potential Visitor:

(Date)Approvals

Head of Organisational/Sponsoring Unit(Name)

(Signature)

(Date)Divisional Head/College Executive Dean/ University College Chief Executive (Name)

(Signature)

(Date)

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University of TasmaniaVisiting Fellowships and Visiting Scholarships Program – Nomination Form

Work Health and Safety Information (for the nominee)

a) Work Health and SafetyIn accordance with the Work Health and Safety Act 2012, a person undertaking a role with the University is to comply with Section 28 of the Act and while at work must:

a) take reasonable care for his or her own health and safety; andb) take reasonable care that his or her acts or omissions do not adversely affect the

health and safety of other persons; andc) comply, so far as the worker is reasonably able, with any reasonable instruction that is

given by the University to allow the University to comply with this Act; andd) co operate‐ with any reasonable policy or procedure of the University relating to health or

safety at the workplace that has been notified to workers. Please find access to the University Work Health and Safety policies and delegations here.

b) Accidents and InjuriesIf a person occupying a position is injured, or has an accident during the carrying out of their duties, they must report it immediately using the online Incident Reporting system or to their Organisational Unit Head or delegate.

c) InsuranceAs the position holder is not an employee of the University of Tasmania they are not covered by Workers’ Compensation insurance.However, they are covered under the University’s Personal Accident Insurance Policy for injuries sustained whilst engaged in authorised activities (Noting an age limit of 80 years and general policy exclusions apply).Refer to the University of Tasmania Insurance Guidelines for further details of insurance information).

d) General Conditions relating to positionsAs the holder of an affiliate position with the University, a person: will not receive any remuneration for affiliate work; must not sub contract work to any other‐ person; must obey all reasonable requests made by the Organisational Unit head or Delegate and if a

dispute arises, should discuss the issue with the Organisational Unit head or Delegate; must comply with all security and office regulations in place at the University; shall not represent themselves as employees of the University of Tasmania. The University of

Tasmania may terminate affiliate appointments at its sole discretion.

e) Medical DisclosureThe University is to be advised of: any pre existing‐ medical condition or injury that would preclude the person from carrying out

all of the duties of the position; any medication that could affect the person’s health and safety or those of others, or the

undertaking of their duties.Note: Completion of Medical Disclosure and Authorisation Forms will be required where participating in: laboratory, workshop, or studio work; field activities; or undertaking required driving.

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University of TasmaniaVisiting Fellowships and Visiting Scholarships Program – Nomination Form

Attachment Appendices:Please ensure the following appendices are included with the nomination: Appendix 1 – Head of Sponsoring Unit supporting statement of support Appendix 2 - Nominee’s curriculum vitae Appendix 3 – Written/email travel quotation from the University’s travel agent

Appendix 1 - Supporting statement for nomination from Head of Sponsoring Organisational Unit outlining the ways in which the visit will address the selection criteria:1. Likelihood of delivering value for money to the University 2. Likelihood of contributing to the purposes of the program: ▪ Strengthening academic networks to underpin ongoing scholarly activity; and/or ▪ Achieving scholarly outcomes (e.g. publications) in key areas, through research leadership and collaborative research; and/or ▪ Enhancing the professional development of UTAS staff through exposure to teaching and learning leaders; and/or ▪ Enhancing educational programs through collaborative teaching projects; and/or ▪ Raising the scholarly and public profile of UTAS. 3. Likelihood of formation of a valuable, ongoing relationship with the visitor 4. Extent of financial contribution from the sponsoring organisational unit and/or other sources. Nominations that include co-funding are encouraged.

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University of TasmaniaVisiting Fellowships and Visiting Scholarships Program – Nomination Form

Appendix 2 - Nominee’s curriculum vitae (including list of publications) – 5 pages maximum.

The curriculum vitae should include:1. Personal Details – Name, Email, Current Position 2. Qualifications 3. Previous appointments during the past 10 years 4. Details of career over the past 10 years5. Ten career-best publications (* relevant to this Visiting Fellowship/Scholar proposal)6. Publications for the past 5 years (Web hyperlinks are preferred)

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University of TasmaniaVisiting Fellowships and Visiting Scholarships Program – Nomination Form

Appendix 3 – An approximation (quote) of travel costs provided by the University’s travel agent ([email protected])

(All travel arrangements funded by the program must be made in accordance with the University of Tasmania’s Travel Policy).

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