Expression of Interest Form: Waikato District Health Board Consumer Council

Adapted in accordance with Section 69 of the Copyright Act 1994 by the Royal New Zealand Foundation of the Blind, for the sole use of persons who have a print disability.

Produced 2017 by Accessible Format Production, Blind Foundation, Auckland, New Zealand.

This edition is a transcription of the following print edition:

Waikato District Health Board Consumer Council—Expression of Interest Form

Transcriber's notes

If reading this volume on a portable braille device, note that this e-text is unproofed by touch.

Space to complete the form is indicated either by 3 hyphens (---), or approximate number of lines or space available on the print page.

Page 1

First name: ---

Last name: ---

Preferred name: ---

Ethnicity, including iwi affiliation if applicable: ---

Address: ---


Home: --- Work: --- Mobile: ---

Email address: ---

Why are you interested in being on the Consumer Council? Tell us about the quality, skills and experience you consider relevant, including your health consumer experience.

(Two thirds of a page)

Page 2

Which areas of health are you particularly interested in?

(Approximately 4 lines)

Are you involved in any consumer and/or community groups or projects? Please tell us about this

(Approximately 6 lines)

Are you currently in paid work? If yes, please tell us about this

(Approximately 4 lines)

Tell us about your work experience. Please provide details of jobs you have held part-time or full-time (paid or voluntary), including self-employment in the last five years

Name of organisation: ---

Year started and finished: ---

Nature of experience: ---

(Appoximately 10 lines)

Page 3

Relevant qualifications and awards

Please tell us of any relevant professional/trade qualification, awards or any other experience you believe is relevant to this role

Qualification: ---

Year achieved: ---

Institution or organisation conferring qualification or award: ---

(Approximately 4 lines)


Please give details of TWO referees relevant to this role and who you authorise us to contact

Name: ---

Role: ---

Organisation: ---

Contact details (Phone and email): ---

Name: ---

Role: ---

Organisation: ---

Contact details (Phone and email): ---


Have you ever been convicted of a criminal offence?

Yes No

Note: All successful candidates will be required to undergo New Zealand Police clearance.

This clearance is subject to the Criminal Records (Clean Slate) Act 2004 and may be subject to the exception contained in section 19(3)(e) of the Criminal Records (Clean Slate) Act 2004. For more information on the exception contained in section 19(3)(e) of the Criminal Records (Clean Slate) Act 2004 please visit

I (please write your full name): ---

Declare that to the best of my knowledge, my answers to the questions in this form are correct.


Please send completed forms to Wendy Entwistle, Quality & Patient Safety, Waikato DHB, Private Bag 3200, Waikato Mail Centre, Hamilton 3240, or email them to Alternatively, please complete the online form via the Waikato DHB website:

Completed forms must be received by 15 October 2017

End of Expression of Interest Form