Consumer Representative Request Form

1. Commitee name(*)
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2. ACT Health Division(*)
   ACT Medicare LocalBusiness and InfrastructureCapital Region Cancer ServicesCritical Care and DiagnosticsE-Health and Clinical RecordsMedicineMental Health, Justice Health and Alcohol and Drug ServicesOperational SupportPathologyPerformance and InnovationPolicy and Government RelationsPopulation HealthQuality and SafetyRehabilitation, Aged and Community CareService and Capital PlanningSurgery and Oral HealthWomen, Youth and ChildrenOtherInvalid Input
3. If other please specify(*)
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4. Meeting Place(*)
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5. Committee Start Date(*)
   
   

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6. Meeting frequency (*)
   WeeklyFortnightlyMonthlyBi-MonthlyQuarterlyYearlyAs RequiredInvalid Input
7. Meeting time(*)
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8. Terms of Reference(*)
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9. Committee contact person(*)
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10. Position(*)
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11. Postal address(*)
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12. Phone number(*)
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13. Fax(*)
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14. Email address(*)
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15. Reimbursement Policy(*)
    I am aware of ACT Health's Consumer, Carer and Community Representative Reimbursement Policy.Invalid Input

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