PERSONAL DETAILS: *

Family name:

Given names:

Title:

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

Date of birth: (dd/mm/yyyy)

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

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

Postal Address:

NEXT OF KIN DETAILS: * (in case of emergency)

Family name:

Given names:

Title:

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

Relationship:

Contact telephone numbers:

Email: *

QUALIFICATIONS AND REGISTRATION STATUS

Please indicate the discipline you are qualified in: *

Please indicate your registration status: *

RESIDENCY STATUS:

What is your residency / visa status: *

What is the name of your visa and sub-class, plus expiry date as shown on your passport (if applicable):

RELIEF AVAILABILITY

Start date: *

(dd/mm/yyyy)

List any dates you are NOT available to provide relief:

(dd/mm/yyyy)

Please indicate the duration you are able to relieve for at any one time: *

Do you have any special needs if you were to provide relief in an rural or remote facility?

Which Health Service Districts are you able to relieve in: *

VERIFICATION OF QUALIFICATIONS, REGISTRATION 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 the Allied Health Relief Pool (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>’.
- an original Certificate of Registration with the relevant discipline Registration Board

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

Have you been subject to disciplinary action by a Registration Board or Association at any time? *

TERMS AND CONDITIONS FOR SUBMITTING AN EXPRESSION OF INTEREST

These terms and conditions govern your submission of the Expression Of Interest (EOI) and your access to and use of the EOI 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 EOI.  If you do not complete the EOI we will be unable to assess your suitability for a position with the Allied Health Relief Pool 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 EOI.  If you wish to update any information you have submitted in the EOI you will also need to submit a new EOI.
• 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. You can apply for access to your information, contained in this Form, under the Information Privacy Act 2009 (Qld). You can find information on the Information Privacy Act at: www.health.qld.gov.au/foi/rti.asp
• While Queensland Health endeavours to ensure that the online transmission of this EOI, 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 EOI shall be at your own risk and Queensland Health accepts no responsibility or liability for any unauthorised access to your information contained in the EOI when it is submitted online over the internet.  Individuals who submit the EOI online should receive an acknowledgement from Queensland Health that the EOI 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 EOI 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 EOI 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 in this EOI is accurate and complete at the time of submission. You also warrant that you have not submitted the EOI 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 EOI. *

DECLARATION

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

FEEDBACK:

How did you become aware of career opportunities with Queensland Health: *

Other Comments / Information

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