Cancer Voices NSW
Online Electronic Request for a Consumer Representative
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 electronic request form in as much detail as possible.
A. Number of Representatives Requested
 
B. Requesting Organisation Details
Name of organisation
Contact person
Position
Postal Address
Suburb
 City
 State
 Postcode
Phone (day)
(evening)
(mobile)
Fax
 Email
Website
 
C. Requested Consumer Representation Details
1. Representation Type Please tick the appropriate box or complete the OTHER section
Working group
Review panel
Focus group
Guideline development panel
Committee
Other (please specify)
Other
2. Name of Working group/Focus group/Committee/ Panel or Other
 
3. Membership composition
 
4. Project description/Terms of reference (in layperson's terms please)
 
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)
 
6. Proposed commitment required from consumer representative
 
Duration of each meeting
Meeting frequency
Times of meetings
AM
PM
Evening
Weekends
First/next meeting date
Meeting location
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.
 
 
Note: It will take approximately four weeks for the nomination and selection process to be completed.
 

Press this button once after completing the form. This will send the information you have typed in the boxes above to us by email.
Click this button to clear all information from the form (use this only if you want to start again)

© 2002-2007 Cancer Voices Inc. NSW (CVN)
Updated: January 1, 2007