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Queensland Stay On Your Feet®

Falls Injury Prevention Collaborative & respective working groups registration form



Mandatory Field Mandatory Fields
Select the group you would like to be a member of:Mandatory Field
b. Member of steering committee
Select which setting primarily applies to your current work:Mandatory Field
b. Community health ( eg. blue care, community health centres, etc)
c. Hospital
d. RACF
   
First Name: Mandatory Field
Surname: Mandatory Field
Title: Mandatory Field
Role in relation to falls prevention: Mandatory Field
Organisation: Mandatory Field
Email: Mandatory Field
Postal Address:
Suburb:
State:
Postcode: Mandatory Field
Telephone: Mandatory Field
Fax:
Mobile:
Website:
   

DISCLAIMER:

Personal information you provide in this form will be used by Queensland Health for the dissemination of information related to falls injury prevention. 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. 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.

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.

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

 


 

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Last updated: 15 February 2011