Adverse Events Learning Programme Expert Advisory Group

Application Form

Please complete all sections of this form. It must be signed and dated. Attach a brief CV detailing your education and training, employment history, specific skills and abilities and any other details that you feel will be useful to support your application. Position being applied for

2 Section 1: Personal Information Title Mr Mrs Miss Ms Dr First Name Last Name Preferred name Iwi Affiliation(s)

Ethnicity Address Telephone number Home Work Mobile Email address

Section 2: Personal Statement What experience do you have in the health sector, either as a professional or consumer or both?

What experience and understanding do you have of whānau Māori experience in health and adverse event review?

What experience and understanding do you have of adverse events and/or adverse event review generally?

What do you believe you would offer the Adverse Events Learning Programme Expert Advisory Group?

Section 3: Professional or academic networks Please describe your professional and/or cultural networks and your involvement with them

3 Section 4: Relevant Experience, Qualifications and Awards Please tell us of any relevant experience, qualifications, publications or awards you believe are relevant to this role Experience/ Qualifications Year Institution or organisation that / Awards: Achieved: conferred the qualification or the award:

Please mention anything else that you believe supports this application

Section 5: Referees Please give details of two referees relevant to this role and whom you authorise us to contact - we will advise you if we intend contacting them Name: Brief description of your working Role: relationship with the referee: Organisation: Contact details: (phone or email)

Name: Brief description of your working Role: relationship with the referee: Organisation: Contact details: (phone or email)

4 Declaration I certify that the information provided is correct and no information has been omitted. By typing your name below you are ‘electronically signing’ this form. Signed Date (type/sign)

Please return the completed application form to Kiri Milne at Health Quality & Safety Commission (HQSC) no later than 5pm, 11 August 2017. By email: [email protected] By post: Kiri Milne Project Manager, Adverse Events Learning Programme Health Quality & Safety Commission PO Box 25496 Wellington 6146

For assistance contact Kiri Milne on 04 901 6074 or [email protected].