The Safety and Quality in Healthcare Special Interest Group (SIG) was established to support CHF’s policy and advocacy work in improving health systems for all consumers – patients, carers and communities. Are you consumer representative or advocate in a health service?Are you interested in improving the safety and quality of health delivery to consumers?Do you have views about how health safety and quality risks can be reduced or practices improved?Participating in the SIG offers consumers the opportunity to review and consult on government initiatives, identify and draw attention to areas for improvement, and support CHF’s policy development and advocacy work.The group advises CHF. Final policy positions are made by the CHF Board.The time commitment is to attend a monthly online meeting and to read documents and provide comments between meetings. No sitting fees or reimbursement is offered to participants.For more information please read our General Purpose and Operation Document or contact Tammy Wolffs, Senior Policy Officer t.wolffs@chf.org.au Your Details Name Prefix - None -MrsMsMrDrMissProfHonAssoc ProfAdj Prof First Name * Last Name * Email * Phone Number * City * Postal Code * Country AustraliaCanadaNew ZealandAfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Saint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos (Keeling) IslandsColombiaComorosCongo, Republic Of TheCongo, The Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzech RepublicCôte d’IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland Islands (Malvinas)Faroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly See (Vatican City State)HondurasHong KongHungaryIcelandIndiaIndonesiaIran, Islamic Republic ofIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKosovoKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesia, Federated States ofMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarReunionRomaniaRussian FederationRwandaSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint Martin (French part)Saint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSerbia and MontenegroSeychellesSierra LeoneSingaporeSint Maarten (Dutch Part)SlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyrian Arab RepublicTaiwanTajikistanTanzania, United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUnited States Minor Outlying IslandsUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Birth Date Day Day12345678910111213141516171819202122232425262728293031 Month MonthJanFebMarAprMayJunJulAugSepOctNovDec Year Year19241925192619271928192919301931193219331934193519361937193819391940194119421943194419451946194719481949195019511952195319541955195619571958195919601961196219631964196519661967196819691970197119721973197419751976197719781979198019811982198319841985198619871988198919901991199219931994199519961997199819992000200120022003200420052006200720082009201020112012201320142015201620172018201920202021202220232024 Which state or territory do you live in? * Location Which of the following best describes your location? * I live in an urban/metropolitan area I live in a regional city or town I live in a rural town or area I live in a remote town or area Are you aged: * 18 to 29 years old 30 to 39 years old 40 to 49 years old 50 to 59 years old 60 years old or over? Prefer not to say Do you identify as a member of any of the following groups [select all that apply]? * Aboriginal or Torres Strait Islander Culturally and linguistically diverse (CALD) Person with a disability (PwD) LGBTIQA+ None I do not wish to answer Other... Do you identify as a member of any of the following groups [select all that apply]? Other... Current SIG member * Yes No Are you currently a member of the SIG? If yes, please submit form now. Activity Subject Activity Date Day Day12345678910111213141516171819202122232425262728293031 Month MonthJanFebMarAprMayJunJulAugSepOctNovDec Year Year20222023202420252026 Why are you interested in safety and quality in health care? * max 250 words What experience or knowledge can you bring to the group? * max 250 words Meeting Times * Can you commit to monthly meetings via videoconference? (2020 Meetings are scheduled for the third Tuesday of each month at 12:30pm - 1:30pm Canberra, Sydney, Melbourne Time) Yes No Outside of the Meeting * Can you commit to checking online forums, such as SharePoint, or emails outside of meeting times to prepare, provide feedback or contribute to group discussions? Yes No Is there anything else that you would like to tell us that might be relevant to your application? max 250 words Confidentiality * I agree Some of the activities completed and discussions had by the feedback groups may be confidential. Do you agree to not distribute any feedback group materials beyond other feedbackg group members without consulting with CHF staff? Privacy * I agree I have read the privacy policy and agree to CHF storing my information for the purposes of contacting me about my application or related matters. Leave this field blank