Number of Representatives Requested:
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Cancer
Voices NSW |
| Mail to: | Cancer Voices NSW PO Box 5016 Greenwich NSW 2065 |
| Cancer Voices NSW provides a voice for all people affected by cancer and we thank you for asking us to help assist your organisation in recruiting consumer representatives for your specific needs. To help us select the best representative for you please complete this request form in as much detail as possible. |
| Application Lodgement Date: |
Number of Representatives Requested:
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| A. Requesting Organisation Details |
| Name of organisation |
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| Contact person | Position |
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| Postal Address |
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| Suburb | City | State | Postcode |
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| Phone (day) | (evening) | (mobile) | |
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| Fax | Website | ||
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| B. Requested Consumer Representation Details |
| 1. | Representation Type Please tick the appropriate box or complete the OTHER section | ||||
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Working group
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Review panel
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Focus
group
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Guideline development panel
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Committee
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Other (please specify)
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| Other: |
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| 2. | Name of Working group/Focus group/Committee/Panel or Other | ||||
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| 3. | Membership composition | ||||
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| 4. | Project description/Terms of reference (in layperson's terms please) | ||||
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| 5. | Experience or interests required from consumer representative If more than one representative is requested please outline full requirements (ie - different gender/different geographical location) |
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| 6. | Proposed commitment required from consumer representative | ||||
| Duration of each meeting | Meeting frequency |
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Times of meetings
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AM
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PM
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Evening
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Weekends
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| First/next meeting date | Meeting location |
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| 7. | Available subsidies for consumer representative We expect travel expenses and other related costs to be met by your organisation. Please specify if subsidies are not available, and the expected costs likely to be incurred. |
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| C. Completed forms |
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Please post completed
forms to: |
| Note: It will take approximately four weeks for the nomination and selection process to be completed. |
| For further enquiries contact Cancer Voices NSW by emailing us at info@cancervoices.org.au |
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© 2002-2007
Cancer Voices Inc. NSW (CVN) |