Clinical Advisory Council EOI

Please complete the following questions:

Full Name *

Surname *

Street Address *Street Address line 2

Suburb *

State *

Postcode *

Email *

Profession *

Name of Practice (if applicable)

Area/s of Clinical Interest *

Selection Criteria

1. Outline your experience in working as part of a committee or council. Please list any clinical groups/memberships you are currently associated with. *

2. Provide an example of how you would advocate/promote the role of Country to Coast, QLD, in your local area? *

3. With your knowledge and expertise, what are three things you would like to see changed most about primary care?

a. *

b. *

c. *

Skills & Experience

CCQ’s Executive will conduct an EOI process for Clinical Council members and make recommendations to the CCQ Board based on the Skills Matrix. The CCQ Board will endorse members.

Diversity and equity factors make up the composition of the Clinical Council. It is also a requirement that individuals have at least one of the professional skills listed below and general experience.

4. Gender *

MaleFemaleNon-binary/otherChoose not to answer

6. Do you identify as a member of any of these groups *

Aboriginal and/or Torres Straits Islander People with disability Culturally and linguistically diverse (if yes, please indicate ancestries in the field below)No

If you selected 'yes' above for culturally and linguistically diverse, please indicate ancestries

8. General Experience

Experience in clinical governanceDemonstrated experience in empowering communities to self manageDeep experience in at least one of the Commonwealth DoH Nine National Health Priority Areas (aged care, Aboriginal & Torres Strait Islander health, digital health, drug & alcohol treatment, maternal and child health, mental health, population health, health workforce, integration and coordination)

9. Conflicts of Interest – Country to Coast, QLD commissions several primary care services, therefore all Clinical Council members are required to declare any potential, perceived or actual conflicts of interest. Please list any associated conflicts that may exist if you were successful in this role. *

10. REFEREE DETAILS

Referee's Full Name *

Referee's Profession *

Organisation *

Referee's Phone Number *

Referee's Email *

Relationship to You *

11. MEETING AVAILABILITY

The Clinical Council meet on a quarterly basis during a weeknight evening between the hours of 6.30pm - 9.00pm. Meetings may be located in the CCQ Offices and/or virtual. Are you be able to prioritise your commitment to attending quarterly meetings? *

YesNo

AGREEMENT

12. By submitting this application, I agree that the facts set forth in it are true and complete. I understand that if I am accepted as a Clinical Council member, any false statements, omissions, or other misrepresentations made by me on this application may default my membership. *

I agree to the above