Healthy living

WA Sexual Health and Blood-borne Viruses Advisory Committee (WA SHaBBVAC) application form

Consumer representative application form

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The details requested will help ensure the committee is comprised of a diverse pool of consumer representatives. The information you provide is confidential and will only be used for the purpose of nomination to a consumer representative position and will not be distributed further without prior permission.

The requirements of the role are outlined in the Expression of Interest (PDF 892KB).

Please submit your completed form by 4.00pm, Friday 20 September, 2019.

You can complete the form below, or fill out the Consumer Representative Application Form (PDF 891KB) and email or post to the details as listed in the document.

Role requirements
I have read and understand the requirements of the role as outlined in the Expression of Interest (PDF 892KB).
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Personal details
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Do you identify as any of the following? (Mark all that apply)


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Please note that submitting an Expression of Interest does not automatically mean you will be selected. The final decision rests with the Chief Health Officer.
If unsuccessful on this occasion, would you like the committee to keep your details on record for similar opportunities in the future? (Your personal details will be kept for a maximum of 12 months.)
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Selection criteria
1. In which area/s do you have a lived experience either as a consumer or carer?


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4. Please provide name, phone number and email of two referees:
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Last reviewed: 22-08-2019
Acknowledgements

Sexual Health and Blood-borne Virus Program


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