1. Please indicate the level of employment you are seeking

1(a). If there are no suitable vacancies in the level of employment you are seeking, would you like to be considered for vacancies at an alternative level?

2. What is your primary specialty or area of interest(eg. Psychiatry, Emergency Medicine)?

Anaesthesia Dermatology Emergency Medicine General Practice Intensive Care Medicine Medicine Medicine – Neurology Medicine – Endocrinology Medicine – Palliative Medicine – Respiratory & Sleep Medicine – Gastroenterology & Hepatology Medicine – Geriatric Medicine – Cardiology Medicine – Clinical Pharmacology Medicine – Internal Medicine Medicine – General Medicine – Nephrology Medicine - Medical Oncology Medicine – Nuclear Medicine – Immunology & Allergy Medicine – Infectious Diseases Medicine – Haematology Medicine – Rheumatology Medicine – Clinical Generics Medical Administration Ophthalmology Obstetrics & Gynaecology O & G – Gynaecologicl Oncology O & G – Maternal – Fetal Medicine O & G - Obstetric & Gynaecological Ultrasound O & G – Reproductive Endocrinology & Infertility O & G Uragynaecology Paediatrics Paediatrics – Anaesthesia Paediatrics – Cardiology Paediatrics – Clinical Genetics Paediatrics – Clinical Pharmacology Paediatrics – Community Child Health Paediatrics – Emergency Paediatrics – Endocrinology Paediatrics – Gastroenterology & Hepatology Paediatrics – General Paediatrics – Haematology Paediatrics – Immunology & Allergy Paediatrics – Infectious Diseases Paediatrics – Medical Oncology Paediatrics – Neonatology Paediatrics – Nephrology Paediatrics – Neurology Paediatrics – Nuclear Paediatrics – Palliative Paediatrics – Perinatology Paediatrics – Respiratory & Sleep Paediatrics – Rheumatology Pain Medicine Palliative Medicine Pathology Pathology – Anatomical (incl Cytopathology Foresic Pathology) Pathology – Chemical Pathology – General Pathology – Haematology Pathology – Immunology Pathology – Microbiology Psychiatry Public Health – Alcohol, Tobacco & Other Drugs Public Health – Sexual Health Public Health Medicine Public Health – Medical Epidemiology Radiology Radiology – Diagnostic Radiology – Diagnostic Ultrasound Radiology – Nuclear Medicine Radiology – Radiation Oncology Rehabilitation Medicine Surgery Surgery – Cardiothoracic Surgery – Ear, Nose & Throat Surgery – General Surgery – Neurosurgery Surgery – Orthopaedic Surgery – Paediatric Surgery – Plastic & Reconstructive Surgery – Urology Surgery – Vascular Surgery (Ctrl key & mouse button to select more than one)

3. Do you seek permanent or temporary employment opportunities?

3(a). If Temporary:

3(b). If Permanent:

4. What is your preferred location of employment in Queensland?*

4(a).  If this location is not available would you consider other locations and where?

4(b). Would you like to work in one location, or would you like opportunities to move around?

PERSONAL DETAILS: *

5. Family name:

6. Given names:

Title:

(eg. Dr/Prof/Mr/Mrs/Ms)

7. Date of birth: (dd/mm/yyyy)

(used to eliminate duplicates, to confirm Visa entitlements and for validation purposes only)

8. Contact telephone numbers: (please include international code and area code)

9. Email: (please note email is our primary method of contacting you)

10. Postal Address:

MEDICAL QUALIFICATIONS

11. Please provide details of your primary medical qualifications: *

12. Please provide details of any post-graduate medical qualifications:

REGISTRATION STATUS

13. Please indicate your registration status: *

CURRENT AND PREVIOUS POSITIONS (important details only):

14. Please list details of your current and your most recent positions: *

VERIFICATION OF QUALIFICATIONS AND WORK EXPERIENCE: *

I verify that the information contained within this Expression of Interest form and attached Curriculum Vitae is true and correct at the date of submission.  I acknowledge that should I be invited for an interview with a Health Service District (and appointed, if successful) that I will be required to provide an original Curriculum Vitae that is signed and includes the following statement on the first page "This Curriculum Vitae is true and correct as at <insert date>"

CONSENT:

“I agree that Queensland Health may, for the purposes of verifying my qualifications, use and disclose my personal details contained in this form, including disclosure to professional and regulatory bodies.”

DISCLOSURE

17. Have you been subject to disciplinary action by a Medical Registration Board at any time? *

TERMS AND CONDITIONS FOR SUBMITTING AN EXPRESSION OF INTEREST

These terms and conditions govern your submission of the Expression of Interest Form (the “Form”) and your access to and use of the Form and related web pages. By using or submitting this form you agree to be bound by these terms and conditions.

• You must complete all sections of the Form. If you do not complete the Form we will be unable to assess your suitability for a position with Queensland Health and will be unable to notify you of any vacancies. The information provided by you will be valid for a period of up to 12 months and will only be retained by Queensland Health for a period of up to 12 months. After this period has expired we will dispose of the information and you will need to submit a new Form. If you wish to update any information you have submitted in the Form you will also need to submit a new Form.
• Personal information you provide in this form will be used by Queensland Health for employment related purposes and / or to determine your suitability for employment within the public health system in Queensland. In addition, we may use your information for statistical purposes; however any information will be de-identified for this purpose. Queensland Health reserves the right to use and disclose the information provided by you in the Form to verify your qualifications and / or standing, including disclosing your information to professional and / or regulatory bodies. We will not disclose your information for any other purpose unless we obtain your consent, or we are required or permitted to do so by law or in accordance with the requirements of Information Standard 42A – Information Privacy for the Queensland Department of Health (“IS42A”). Your information, contained in this Form, will be potentially open for release under the Freedom of Information Act 1992, Queensland. You can access this legislation through the following link: http://www.legislation.qld.gov.au/LEGISLTN/CURRENT/F/FreedomInfoA92.pdf
• While Queensland Health endeavours to ensure that the online transmission of the Form, containing your information, over the internet is secure, the inherent nature of the internet means that there is a potential risk that your information may be viewed or intercepted by third parties. Accordingly, submission through the online Form shall be at your own risk and Queensland Health accepts no responsibility or liability for any unauthorised access to your information contained in the Form when it is submitted online over the internet. Individuals who submit the Form online should receive an acknowledgement from Queensland Health that the Form has been sent, on the screen, following submission. Queensland Health accepts no responsibility or liability if this acknowledgement does not appear or we do not receive your online submission.
• Queensland Health makes no representation at the time the Form is submitted or any time in the future, that there is a suitable position or any position, available to you, or that you will be considered for a position that becomes available in Queensland Health. In addition, Queensland Health makes no representation that by submitting your Form you will be notified of any or all appropriate vacancies; offered an interview in relation to a vacant position; or be offered a position with Queensland Health.
• You warrant that the information you submit on this Form is accurate and complete at the time of submission. You also warrant that you have not submitted the Form on behalf of any other person.

You acknowledge that you have read and understood Queensland Health’s Privacy Statement and Disclaimer.

I hereby accept and agree to abide by, the above terms and conditions for submitting this Form. *

DECLARATION:

I declare the information on this form to be correct at the time of submission. *

FEEDBACK:

18. How did you become aware of career opportunities with Queensland Health?: * (Min 1 - Max 3)

19. Any other comments relevant to your Expression of Interest?

Work For Us Contact Details:

Ph: 1800 000 093 (Within Australia only) or +61 7 3636 9908
Email: workforus@health.qld.gov.au

* = Required fields