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* 1. Name

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* 2. Address

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* 3. Phone

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* 5. Referee Details
For example, this person who knows of you through sport, community groups, work

Please answer the following questions with brief notes

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* 6. Why do you wish to nominate for the SA Pathology Representative Community?

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* 7. What experience or understanding of SA Pathology services or facilities do you have? For example, “my child was seen in a patient centre”, “I have been a client for many years and been to various Collection Centres as well as within Hospital setting”

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* 8. What skills, experience, knowledge or interests do you have that are relevant to your nomination? Please note: SA Pathology will provide training and support for Consumer Representatives

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* 9. Do you have previous experience representing the views of consumers, carers and / or your community? For example, you may have volunteered at a community centre. Please note: it is not important if you haven’t had any experience.

Please note: Any information you provide in this Nomination Form will be kept strictly confidential and will be stored in a secure file. Your personal information will be used by the relevant SA Pathology staff for the purposes of determining whether your skills and experience are a good match for the position you are applying for. Your personal information will not be disclosed to third parties, except where required by law.

Thank you for taking the time to express your interest in a Consumer Representative Role within SA Pathology. You will be contacted within 10 business days to acknowledge your application by email from HealthSAPathconsumerfeedback@sa.gov.au or 15 business days by post.

For more information
Adelaide Musolino - Consumer Engagement Officer
T: 0466 574 493
Health.SAPathologyConsumerEngagement@sa.gov.au

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