Steering Group Nomination Form

Victorian and Queensland farmers are invited to help shape the future of farming families and agricultural workers as part of a National Health Medical Research Council research project – Shh hearing in a farming environment.

Applications are invited from farmers for the Shhh hearing in a farming environment steering group. Three farmers will be appointed and will help steer the project and identify areas for further research or service delivery along with representatives from the project management team. Sitting fees will be paid and support provided. It is envisaged four days a year will be required.

Applications close November 18th, 2012

Name: *

Please enter the name of the person to be nominated.

Are you currently a member or affiliated with a Group or Organisation?: *

Yes

If yes, please advise name of Group or Organisation:

Postal address:

Telephone: *

Mobile:

Email address: *

Please outline why you would like to be a member of this committee?: *

What are your particular interests in farming health, well-being or farm safety?:

Please provide a list of personal attributes and qualifications you will bring to this committee:

Please provide any other information that you wish to include?:

Availability and preferred meeting times. Please nominate any days that would preclude you attending meetings:

Application confirmation

Privacy Notification:

ATTENTION: Applicant - Privacy Notification Form
The personal information that Western District Health Service is collecting from you is personal information for the purposes of the Privacy and Personal Information Protection Act 1998 (“the Act”). The information may only be made available through this or other relevant Acts and Regulations that may apply.
The intended recipients of the personal information are:
•	officers within the Council; 
•	agents or data service providers engaged by the Western District Health Service
•	Western District Health Service agendas
The supply of the information by you is voluntary. If you cannot provide or do not wish to provide the information sought, the Western District Health Service will be unable to process your application.
Western District Health Service is collecting this personal information from you in order to process this committee nomination.
If elected to a committee
•	Your name will also be printed in the reports of Committees and published on Western District Health Service and Sustainable Farm Families Web Page
•	Your name and contact details may be made available to other committee members
You may make application for access or amendment to information held by Western District Health Service. You may also make a request that Western District Health Service suppress your personal information from a public register. Western District Health Service will consider any such application in accordance with the Act. Enquiries concerning this matter can be addressed to the Chief Executive Officer of Western District Health Service.

Applicant confirmation: *

Please enter your name as confirmation that you have read the details above.

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Last reviewed:

31-October-2012

Steering Group Nomination Form

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