Health Care Quality Committee

Expression of Interest

Northern NSW Local Health District is seeking expressions of interest from individuals living in Northern NSW for appointment to the District Board's Health Care Quality Committee (HCQC) as a community representative.

Please review the Expression of Interest prior to completing the following application. Applications close 29 September 2023.

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* 1. Applicant details

Name:

Address:

Town:

Post code:

Email Address:

Phone Number:

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* 2. Your age group

18-25

26-35

36-45

46-55

56-65

66+

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* 3. Which of these describes you? You can select more than one:

Community member

Carer

Aboriginal or Torres Strait Islander person

Mental health consumer

Mental health carer

Identify as LGBTIQ+

A member of a cultural or ethnic group

A person from a non-English speaking background

Person with a disability

Other (please specify) or additional information

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* 4. Which of these describes your occupation? You can select more than one:

Employed (please include your current occupation below)

Carer

Studying

Retired

A current or past practicing health care professional (please include your profession below)

Prefer not to say

Other (please specify) or additional information

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* 5. What health services have you accessed in Northern NSW in the past five years? You can select more than one:

Hospital (Lismore, Tweed, Grafton, Maclean, Ballina, Byron, Murwillumbah, Casino)

Multi-Purpose Service (Bonalbo, Kyogle, Nimbin, Urbenville)

Community and Allied Health (physiotherapist, psychologist, dietitian, podiatrist, counselling, community nursing, etc.)

Mental health services

Drug and alcohol services

Aboriginal Health

Maternity services

Aged care services

Specialist

General Practice

Private hospital

Other (please specify) or additional information

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* 6. Briefly describe your skills and experience of the health system and/or as a health consumer representative?

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* 7. Please list any clubs, community or health-related organisations or networks you are/have been associated with:

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* 8. Please provide the name of two referees to support your application. This can be an employer, someone in community groups that you are part of, a friend, or people who know you in the community.

Referee 1 Name:

Contact Number:

Referee 2 Name:

Contact Number:

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* 9. Nominating member’s statement: Please tick all boxes.

I have reviewed the Expression of Interest prior to completing this application.

I understand that if I am short-listed, I will be required to complete a National Police Check. Northern NSW Local Health District will pay for and arrange this check.

I understand that if I am appointed, I will be required to sign a Code of Conduct and a Confidentiality and Privacy Agreement and provide evidence of having received at least two doses of an approved COVID-19 vaccination.

I agree to disclose affiliations to community, health, political or religious organisations and any potential conflicts of interest.

Thank you for your interest.