Personal details Full name: Phone number: Email: Address: Postcode: By completing this application I consent for my details to be added to the Health Yes No Consumers Queensland network database I would like to receive email updates from Health Consumers Queensland Yes No Are you happy for Health Consumers Queensland to share this form with Allied Yes No Health Professions’ Office of Queensland as part of the process for this application? Would you like us to retain this application for future vacancies Yes No Applications not retained are destroyed once the application process is complete. Please highlight any group that you identify as being a part of: Living with a disability/chronic condition Culturally or linguistically diverse Caring for someone with a disability From a non-English speaking background Physically isolated or transport disadvantaged     Do you identify as: Aboriginal Torres Strait Islander Both Prefer not to state   Are you a: Consumer Carer       70+ Age range 16-24 25-29 30-39 40-49 50-59 60-69 Have you received care from an Allied Health professional in the past 12 months? Yes No Other needs and requirements Is there anything that will help you participate in this activity more fully? Yes No If yes, please provide details eg disability support worker, interpreter, closed captioning, hearing loop, central position to enable better hearing, etc.
Personal details Full name: Phone number: Email: Address: Postcode: By completing this application I consent for my details to be added to the Health Consumers Queensland network database Yes No I would like to receive email updates from Health Consumers Queensland Yes No Are you happy for Health Consumers Queensland to share this form with Allied Health Professions’ Office of Queensland as part of the process for this application? Yes No Would you like us to retain this application for future vacancies Applications not retained are destroyed once the application process is complete. Yes No Please highlight any group that you identify as being a part of: Living with a disability/chronic condition Caring for someone with a disability Physically isolated or transport disadvantaged Culturally or linguistically diverse From a non-English speaking background Do you identify as:  Aboriginal  Torres Strait Islander  Both  Prefer not to state Are you a:  Consumer  Carer Age range  16-24  25-29  30-39  40-49  50-59  60-69 70+ Have you received care from an Allied Health professional in the past 12 months? Yes No Other needs and requirements Is there anything that will help you participate in this activity more fully? Yes No If yes, please provide details eg disability support worker, interpreter, closed captioning, hearing loop, central position to enable better hearing, etc.
HCQ-EOI-form-Working-Group.docx