Cancer Voices Australia – Online request for a consumer representative

Cancer Voices Australia provides a voice for people affected by cancer at the national level. We thank you for asking us to assist your organisation in recruiting informed consumer representatives for your specific, national level needs. To help us select the best nominee 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 *

Address *

Street AddressApt, Suite, Bldg. (optional)CityState / Province / RegionPostal / Zip CodeCountry

Phone

Email *

Website

C. Requesting consumer representative details

1. Representation type

Please tick the appropriate box or complete the Other sectionCommitteeReview PanelResearch projectGuideline development panelWorking groupBoardOther

2. Title of working group/research project/committee/panel or other *

3. Membership composition

4. Project description/ Terms of reference *

(in layman's terms please)

5. Experience or interests required of the consumer representative

Please outline full requirements (ie. cancer type/gender/geographical location)

6. Proposed commitment required from the consumer representative

Meeting duration

Meeting location

Time of meetings

AMPMEveningWeekends

First/next meeting date

Meeting frequency

In person or via teleconference

In personVia teleconference

7. Available subsidies for the consumer representative

We expect travel 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 may take up to two weeks for the nomination and selection process to be completed, although we will aim for a speedier turn around.

Online request for a consumer representative

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