Personal Details Surname: Given Name: Address: Postcode: Phone No.: Email: Mob: Please highlight to indicate your response Do you identify as Aboriginal and/or Torres Strait Islander? Yes No Do you identify as being Culturally or Linguistically Diverse? Yes No Do you identify as being from a non-English speaking background? Yes No Do you identify as being transport disadvantaged or physically isolated? Yes No Do you identify as having a disability? Yes No By completing this application I consent for my details to be added to the I do not Agree Health Consumers Queensland network database agree Are you happy for Health Consumers Queensland to share this form with the Patient Safety and Quality Improvement Service as part of the Yes No process for this application? Would you like Health Consumers Queensland to retain this application for future vacancies? Applications not retained are destroyed once the Yes No application process is complete. Support Requirements Yes No I will require support to attend these meetings If yes, please provide details and indicate other support that you require, for example, disability support worker, interpreter, Auslan interpreter, closed captioning, hearing loop, dietary requirements etc. Dietary requirements Yes No I have special dietary requirements
Personal Details Surname: Given Name: Address: Postcode: Phone No.: Mob: Email: Please highlight to indicate your response Do you identify as Aboriginal and/or Torres Strait Islander? Yes No Do you identify as being Culturally or Linguistically Diverse? Yes No Do you identify as being from a non-English speaking background? Yes No Do you identify as being transport disadvantaged or physically isolated? Yes No Do you identify as having a disability? Yes No By completing this application I consent for my details to be added to the Health Consumers Queensland network database Agree I do not agree Are you happy for Health Consumers Queensland to share this form with the Patient Safety and Quality Improvement Service as part of the process for this application? Yes No Would you like Health Consumers Queensland to retain this application for future vacancies? Applications not retained are destroyed once the application process is complete. Yes No Support Requirements I will require support to attend these meetings Yes No If yes, please provide details and indicate other support that you require, for example, disability support worker, interpreter, Auslan interpreter, closed captioning, hearing loop, dietary requirements etc. Dietary requirements I have special dietary requirements Yes No