Expression of interest: Gold Coast Health Community Advisory Group (CAG)

Get involved at Gold Coast Health

The information on this form is treated confidentially.

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* 1. Your name

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* 2. Phone

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* 3. Mobile

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* 4. Email

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* 5. Suburb

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* 6. Your age

18-25

26-35

36-45

46-55

56-65

65+

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* 7. Gender

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* 8. Do you identify as

An Aboriginal or Torres Strait Islander

A member of a cultural or ethnic group

A person with a disability

A person from a non-english speaking background

Other (please specify)

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* 9. Are you (please choose all that apply)

A carer

Studying

Retired

Working (please state your current occupation below)

A current or past practicing health care professional

Prefer not to say

Other/comments (if required)

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* 10. Do you have any clinical or health professional experience?

Yes

Please specify

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* 11. What health services have you accessed on the Gold Coast in the last five years?

Gold Coast University Hospital

Robina Hospital

Private hospital

Allied Health (physio, podiatrist, psychologist, dietician,etc)

Specialist Yes

Aged care service

General Practice (GP) Yes

None

Other (please specify)

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* 12. Please list any clubs, community groups or networks you are currently connected with

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* 13. Can you commit to attending meetings every three months on a Wednesday at Gold Coast University Hospital?

Yes

Yes - prefer a morning meeting

Yes - prefer an afternoon meeting

Yes - prefer an evening meeting

Other (please specify)

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* 14. Why are you interested in being a member of the Gold Coast Health Consumer Advisory Group?

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* 15. Please tell us if there is any other information you would like the selection panel to consider or know about yourself

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* 16. If you are not selected to join the Gold Coast Health Consumer Advisory Group, please advise how you would like your application handled?

Keep my application on file and contact me if a vacancy opens on the GCH Consumer Advisory Group

Keep my application on file and consider me for other consumer opportunities at Gold Coast Health

Add me to your distribution list to be invited to participate in on-line consultations

Add me to your distribution list to receive Gold Coast Health information

Delete my application

Thank you for taking the time to complete an expression of interest for the Gold Coast Health Consumer Advisory Group.

Expressions of interest close on 10 March 2017. Applications must be received by the closing date.

Compliance with Information Privacy Act 2009 (Qld) (IP Act): Surveys on this site are conducted using SurveyMonkey which is based in the United States of America (USA). Information you provide on surveys will be transferred to SurveyMonkey’s server in the USA. By completing this survey, you agree to this transfer.