Application Form

Please complete all the questions as they apply to you in the following application form and click submit. If you haven’t completed a mandatory field it will prompt you to complete the question before you can submit the form.

Please note the expected time commitment for Hospital and Health Board Members is approximately three (3) days per fortnight and for Hospital and Health Board Chairs is approximately five (5) days per fortnight.

Title

First Name

Middle Name(s)

Last Name

Postnominals (Australian Honours List Only)

All previous and other names (including first, middle and last names) known by (maiden/ previous/ preferred etc.)

Preferred Name

Name as per CV

Name on Licence or Passport

Date of Birth

Place of Birth

State or Territory of Birth (if outside of Australia, please select Overseas)

Residential Address (number and street name)

Suburb/City

State

Postcode

Postal Address Complete if your residential address is different to your residential address

Phone number

Email Address

Note: The Remuneration Procedures for Part-time Chairs and Members of Queensland Government Bodies defines 'Public sector employees' as employees of federal, state or local governments, employees of semi-government organisations, either federal or state, including statutory authorities and employees of state and local government owned corporations and colleges. For the purpose of these procedures members of any parliament within Australia, elected local government representatives, judges, magistrates and other judicial and quasi-judicial officers are also regarded as public sector employees. Paid officials or employees of universities are not included in this category. Are you a public sector employee?*

NoYes, please provide the following information

Name of department or agency

Current role

Name of Chief Executive

Chief Executive email address

Are you currently a member of a Hospital and Health Board?

NoYes, please provide details of your current board

Please indicate which position you are applying for:

ChairpersonMemberBoth

Which Hospital and Health Board are you applying for?

Central Queensland

If unsuccessful in your preferred board, would you be happy to be considered for an alternate board that requires your skills?

NoYes

Are you, or have you ever been, a health practitioner (within Australia or oversees)? (if you answer YES, you must supply more information in the text field)

NoYes, please advise what is/was your profession

Are you currently registered as a health practitioner under the Health Practitioner Regulation National Law (the National Law), as in force in each state and territory? (if you answer YES, you must supply more information in the text field)

NoYes, please provide your registration number

Do you hold specialist registration as a medical practitioner with the Medical Board of Australia? (if you answer YES, you must supply more information in the text field)

NoYes, please provide the following information

What is your specialty?

What is your field of speciality practice (if applicable)?

Is your registration as a health practitioner under the National Law subject to conditions that limit your right to practice the profession or have you entered an into an undertaking with the relevant National Board?

NoYes, please provide details

Please provide details of two referees:

Referee 1 Name

Referee 1 Organisation

Referee 1 Position

Referee 1 Phone

Referee 1 Email

Referee 1 Professional Relationship to applicant

Referee 2 Name

Referee 2 Organisation

Referee 2 Position

Referee 2 Phone

Referee 2 Email

Referee 2 Professional Relationship to applicant

Diversity information

Deidentified data may be provided to relevant authorised officers to support the Queensland Government’s commitment to developing strategies and programs to promote diversity and inclusion on Queensland Government boards, committees and other government bodies. These questions are optional, if you do not wish to disclose this information please select 'I do not wish to answer this question'

Gender

FemaleMaleNon-binaryI do not wish to answer this question

Are you under 35 years old?

NoYesI do not wish to answer this question

Aboriginal and/or Torres Strait Islander people

Aboriginal people and Torres Strait Islander people are the First Peoples of Australia. An Aboriginal and/or Torres Strait Islander person is a person who is of Aboriginal and/or Torres Strait Islander descent and who identifies as such and is accepted as such by the Aboriginal and/or Torres Strait Islander people in the community in which they live or have lived.

Are you an Aboriginal and/or Torres Strait Islander person?

Yes, I am an Aboriginal personYes, I am a Torres Strait Islander personYes, I am both an Aboriginal and Torres Strait Islander personNo, I am not an Aboriginal or Torres Strait Islander personI do not wish to answer this question

Australian South Sea Islander people

Australian South Sea Islander people are the direct descendants of South Sea Islanders brought to Australia between 1863 and 1904 to work as indentured labourers.

Are you an Australian South Sea Islander person?

Yes, I am an Australian South Sea Islander personNo, I am not an Australian South Sea Islander personI do not wish to answer this question

Disability

A disability is a limitation, restriction or impairment which has lasted, or is likely to last, for a least six months and restricts everyday activities. There are many kinds of disability, usually resulting from accidents, illness or genetic disorders, and may include:

Physical
Sensory
Intellectual
Mental illness
Neurological

Do you identify with the above?

Yes, I identify as having a disability/disabilitiesNo, I do not identify as having a disabilityI do not wish to answer this question

Culturally and Linguistically Diverse people

A Culturally and Linguistically Diverse person is a person who identifies as all or any of the following:

born overseas, including English-speaking countries
identify with a different cultural background other than Australian, including identifying with more than one culture e.g. Chinese-Australian
speak a language at home besides English (including Aboriginal and Torres Strait Islander languages).

In which country were you born?

Born in AustraliaBorn overseas in a mainly English–speaking country, including but not limited to, New Zealand, United Kingdom, Ireland, Canada, United States of America and South AfricaBorn overseas in a mainly non-English speaking countryI do not wish to answer this question

Do you speak a language other than English at home? This includes Aboriginal or Torres Strait Islander languages?

YesNoI do not wish to answer this question

LGBTIQ+

LGBTIQ+ is an acronym describing people of diverse sexual orientations, gender identities and sex characteristics, short for lesbian, gay, bi-sexual, transgender, intersex and queer. The + reflects that the letters of the acronym do not capture the entire spectrum of sexual orientations, gender identities and intersex variations, and is not intended to be limiting or exclusive of certain groups.

Do you identify as an LGBTIQ+ person?

YesNoI don't knowI do not wish to answer this question

Please indicate where you first heard about these opportunities.

Job Boards

Newspapers

Regional Newspapers

Government sources

Member Networks

Other (e.g. Word of Mouth, other advertising channel)