Consumer Representative - Expression of Interest Question Title * 1. Contact Details Title and Full Name Address Email Address Phone Number ABOUT YOU: Question Title * 2. Gender: Question Title * 3. Age: 18-30 31 - 45 46 - 65 65+ Question Title * 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 Question Title * 5. Do you identify from a culturally and/or linguistically diverse background (CALD) Yes No Question Title * 6. Is English your first language? Yes No Question Title * 7. If no, language spoken at home? Question Title * 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 Question Title * 9. If yes, would you require any special workplace adjustments to help you? Question Title * 10. Do you have a current Working with Children Check (blue card)? Yes No Question Title * 11. Do you have a current Disability Worker Screen Check (yellow card)? Yes No CONSUMER REPRESENTATION: Question Title * 12. Please outline why you would like to join our organisation as a Consumer Representative: Question Title * 13. How would you like to be involved? What are your areas of interest? 1. 2. 3. Question Title * 14. Do you have any previous experiences as a Consumer Advisor/Representative? Yes No Question Title * 15. If yes, please provide more information? Question Title * 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 Question Title * 17. Have you undertaken any previous consumer training? Yes No Question Title * 18. If yes, please tell us what you have done and where it was completed: Question Title * 19. Please indicate availability below: Online, email and phone Meetings if required (working hours) Meetings if required (evening/after hours) Question Title * 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 Question Title * 21. If yes, please name the organisation, describe your role and include recent activities that you have carried out. Question Title * 22. Are you a member of any social, community or charitable organisations or networks? If so, please provide additional information below: 1. 2. 3. Question Title * 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: Question Title * 24. Friendliness: Question Title * 25. Diligence: Question Title * 26. Courage: Question Title * 27. Wisdom: Question Title * 28. Compassion: Thank you.