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

Health Consumer Network

Registration Form

 
PERSONAL DETAILS

Join HCQ's Health Consumer Network by completing and submitting this form to the HCQ Secretariat. Network members are eligible to participate in the HCQ Consumer Representatives Program, receive information about health consumer related issues and opportunities to provide feedback to HCQ on important health matters.
   
Surname:required Given Names:required
Home Address: Postcode:
Postal Address:required Postcode:required
Preferred Contact Phone:required Email:required
Gender: Male Female
Age Range: 18-24 yrs    25-39 yrs   40-54 yrs    55-69 yrs    70 yrs +
Do you wish to join HCQ's Health Consumer Representatives Program? Yes No
Do you wish to receive HCQ's regular information updates via email? Yes No
Please tick the response most relevant to you.
INFORMATION ABOUT YOU
For approximately how many years?
b) I am a carer
c) I am a member of professional or academic body

If yes, please specify:

d) I am a current or past practicing health care professional

If yes, please specify:

e) I am a member of a human service/community service/ or welfare organisation

If yes, please specify:

f) I am a member of an advocacy or rights based organisation

If yes, please specify:

g) I am an employee of a government agency at the local, state or national level

If yes, please specify:

h) I am a statutory officer eg. Public Advocate

If yes, please specify:

i) I am a member of the Health Community Council/ health advisory group

If yes, please specify:

j) I am an Aboriginal or Torres Strait Islander  
k) I am a person with a disability  
l) I am a person from a Non-English Speaking Background  
Are you a member of any community networks or groups? Eg. Support groups, interest groups, leisure clubs etc Yes No

If yes, please provide details of the group/s:
INFORMATION ABOUT YOUR EXPERIENCE
What geographical areas do you have consumer knowledge and experience of?
Remote Regional Metropolitan

Please indicate if you have experience representing any of the following areas?
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:  
I have relevant experience as a health consumer

If yes, please provide details:
   
I have experience in health advocacy

If yes, please provide details:

 
I have experience in forums, community or government committees, boards of management, advisory/reference groups, consultations, etc.

If yes, please provide details:
Areas of Interest
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
   

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