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Consumer Representative - Expression of Interest
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1.
Contact Details
(Required.)
Title and Full Name
Address
Email Address
Phone Number
ABOUT YOU:
2.
Gender:
3.
Age:
18-30
31 - 45
46 - 65
65+
4.
Nationality: Do you identify as:
Aboriginal
Torres Strait Islander
Both Aboriginal and Torres Strait Islander
Not Aboriginal and Torres Strait Islander
Prefer to not say
5.
Do you identify from a culturally and/or linguistically diverse background (CALD)
Yes
No
6.
Is English your first language?
Yes
No
7.
If no, language spoken at home?
8.
Do you have a disability? (please note the definition of disability includes sensory, intellectual, neuro-diverse, physical and mental illness - where the disability is permanent or is likely to be permanent)
Yes
No
9.
If yes, would you require any special workplace adjustments to help you?
10.
Do you have a current Working with Children Check (blue card)?
Yes
No
11.
Do you have a current Disability Worker Screen Check (yellow card)?
Yes
No
CONSUMER REPRESENTATION:
12.
Please outline why you would like to join our organisation as a Consumer Representative:
13.
How would you like to be involved? What are your areas of interest?
1.
2.
3.
14.
Do you have any previous experiences as a Consumer Advisor/Representative?
Yes
No
15.
If yes, please provide more information?
16.
Which applies to your experience:
I am a patient
I am a former patient
I am a carer or family member
I have been both a patient and a carer/family member
17.
Have you undertaken any previous consumer training?
Yes
No
18.
If yes, please tell us what you have done and where it was completed:
19.
Please indicate availability below:
Online, email and phone
Meetings if required (working hours)
Meetings if required (evening/after hours)
20.
Are you currently involved with any consumer organisations and/or acted or currently act as a consumer representative on a Committee or Board?
Yes
No
21.
If yes, please name the organisation, describe your role and include recent activities that you have carried out.
22.
Are you a member of any social, community or charitable organisations or networks? If so, please provide additional information below:
1.
2.
3.
23.
What qualities and life skills do you feel you would contribute as a consumer representative with our organisation?
Our hospital values are - Friendliness, Diligence, Courage, Wisdom and Compassion. Please outline briefly how you would contibute to each of these:
24.
Friendliness:
25.
Diligence:
26.
Courage:
27.
Wisdom:
28.
Compassion: