Northern NSW Local Health District

Tweed Valley Hospital Community Reference Group Expression of Interest
Closing Date 6 June 2018

Northern NSW Local Health District (NNSW LHD) is building a new Tweed Valley Hospital. An essential part of this process is to plan the clinical services that will be delivered into the future. It is expected that existing services will be strengthened and new services, such as radiotherapy and cardiac services will be introduced.
The planning for future services will be developed into a Service Statement document. NNSW LHD is seeking expressions of interest from residents of the Tweed Shire who are users (or carers thereof) of Tweed Shire health services to join a community reference group to advise on the health services that are needed into the future.

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* 1. Applicants details

Full Name:

Preferred mailing address:

Post code:

Suburb residing in:

Preferred telephone contact:

Email Address:

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* 2. Age Group

16-25

26-35

36-50

51-65

over 65

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* 3. Which of these describes you? You may select more than one option.

Carer

Aboriginal or Torres Strait Islander

South Sea Islander

Person with a disability

Aged pensioner

From a culturally diverse background

Other (please specify)

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* 4. Please tick any of the following which relate to your work/ work status

Education sector

General Practice

Health sector

Local Government

Mental Health

Non-Government

Retired

Student

Volunteer

Other (please specify)

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* 5. Which of the following services have you or the person you care for used in the past 12 months?

Aboriginal Health

Aged Care

Cancer services

Children's/ Paediatric

Disability

Drug and Alcohol

Emergency Department

Maternity

Medical/ surgical

Mental Health

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* 6. What makes you a good representative of health consumers and of your local community?

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* 7. Please provide details if you are a member of any community groups or organisations?

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* 8. Please provide details of any experience as a community representative or other experience/ skills to support your application

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* 9. Nominating Committee member’s statement:

I understand that my information will be kept confidential by the Northern NSW Local Health District. I understand that I will be reimbursed for travel expenses, however will not be paid for my participation.

If unsuccessful:

I agree to my details being kept confidential and would like to be contacted about other opportunities to be involved

Please destroy my information following the selection process.

Should you be successful in your EOI you will be required to complete a 100 point identity check and a Criminal Record Check Consent Form.

THANK YOU - WE WILL CONTACT YOU AFTER THE CLOSING DATE (6 June 2018)

If you are completing this Expression of Interest Form in hardcopy or PDF format, please email back to NNSWEngagement@ncahs.health.nsw.gov.au

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* 1. Applicants details

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* 2. Age Group

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* 3. Which of these describes you? You may select more than one option.

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* 4. Please tick any of the following which relate to your work/ work status

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* 5. Which of the following services have you or the person you care for used in the past 12 months?

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* 6. What makes you a good representative of health consumers and of your local community?

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* 7. Please provide details if you are a member of any community groups or organisations?

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* 8. Please provide details of any experience as a community representative or other experience/ skills to support your application

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* 9. Nominating Committee member’s statement: I understand that my information will be kept confidential by the Northern NSW Local Health District. I understand that I will be reimbursed for travel expenses, however will not be paid for my participation. If unsuccessful:

* 9. Nominating Committee member’s statement:

I understand that my information will be kept confidential by the Northern NSW Local Health District. I understand that I will be reimbursed for travel expenses, however will not be paid for my participation.

If unsuccessful: