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Queensland Government
Link to Queensland Government (www.qld.gov.au)
 
Queensland Health
About us > Health Consumers Queensland

Consumer Representatives Program

Agency Request For Consumer Representative

Health Agencies can make a request for a health consumer representative through the HCQ Consumer Representatives Program by completing and submitting this form to the HCQ Secretariat.
REFERRING AGENCY DETAILS
Organisation Name:required
Address:required  Postcode:required
Contact person:required  Position:required
Contact Phone:required  Email:required
Services provided by organisation:
Target population group of organisation:
COMMITTEE INFORMATION
Please note that committee describes any reference group, board, consultation forum, committee, working group, etc.
Purpose of committee:required
Aim/s of committee: (include any Terms of Reference)

What is the potential impact on health consumers / what are the benefits of this initiative?

What are the key areas that committee will be looking at?required

Number of Consumer Representatives required:required

Type of request:required

Workshop

 Forum Committee
Advisory Body Reference group Other
Timeframe of consumer participation required:required

One off event
Specific period of time
Please specify:
Details of committee meeting location:required

Please provide the relevant information: Commencement date:required
Finish date:required
Meeting time/s:required
Frequency of meeting/s:required
Other information:
What supports / remuneration / reimbursement will the agency provide the Consumer Representative?required
Travel / Accommodation
Interpreter
Induction
Reimbursement of expenses
Admin Support
Support Worker for people with a disability
Carer support
Other,  Please specify:
 
INFORMATION ABOUT CONSUMER REPRESENTATIVE REQUEST
What is the scope of the consumer representative role on this committee?

SCOPE OF CONSUMER REPRESENTATIVE ROLE
The consumer to provide information and feedback to the Agency
The consumer to provide direct advice to inform developing solutions/decision making
Consumer feedback to be considered and influence future solutions/decision making

What are the Agency's expectations of consumer representation on this committee?
AGENCY'S EXPECTATIONS
The Consumer Representative to share common perspectives of a population group.
Please specify which population group:
The Consumer Representative to express opinions as a past consumer of a particular service.
Please specify:
 
INFORMATION ABOUT CONSUMER EXPERIENCE
Please outline what skills, knowledge base and other attributes you seek in a consumer representative for this committee. Please provide any further information which would support consumer representative request process
What geographical areas do you seek consumer knowledge and experience of?
Rural        Remote       Regional         Metropolitan

Please indicate which of the following areas you seek a consumer representative to have experience representing? Please indicate if you have a higher or lower priority for a particular skill or experience that is needed.
Aboriginal and/or Torres Strait Islander Rural/Regional Remote
Financially disadvantaged Disability Families
Young People Older persons Women
Homelessness Mental Illness Maternal and child health
Adults Prison populations Substance abuse
Carer Men's health People with impaired decision making capacity
Culturally and linguistically diverse communities

Chronic disease/ illness Please specify:

Lesbian, gay, bisexual and transgender communities
Other - Please specify:    
Areas of Health Service Interest / Experience
Children and Youth Indigenous health Maternal health
Emergency Health Palliative care Health promotion
Outpatients Mental Health Prevention
Aged Care Intensive Care Allied Health services
Men's Health Carers Women's health
Disability Diagnostic services Community health
Chronic illness/disease
Please specifiy: 		Other
Please specifiy: 		Health research
 
Please indicate if you have a higher or lower priority for a particular skill or experience that is needed.
   
 

Privacy Statement

Health Consumers Queensland Secretariat, as part of Queensland Health is bound by the National Privacy Principles in the Information Privacy Act 2009.  Only authorised officers of the department will have access to your personal information which will not be disclosed to any other third party without your consent, unless authorised or required by law.

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Last Updated: 17 June 2009
Last Reviewed: 17 June 2009