COMPANY NAME

FIRST NAME*

SURNAME*

ADDRESS*

HOUSE NO.

STREET*

SUBURB*

STATE*

State ACT Qld NSW NT SA Tas Vic WA

POSTCODE*

POSTAL ADDRESS

or

As above

PO BOX

STREET

SUBURB

STATE

State ACT Qld NSW NT SA Tas Vic WA

POSTCODE

E-MAIL ADDRESS

TELEPHONE*

Area Code:

Number:*

FAX

Area Code:

Number:

MOBILE

Question 1.

What do you know about Sydney West Area Health Advisory Council?

Question 2.

Do you feel confident in having the Area Health Advisory Council in place?

Yes

No

for any particular reason?

Question 3.

Are you a member of a community group?

Yes

If yes, which one(s)

Community Group Title:

No

Question 4.

Are you:

1. A member of a Profession

Yes

If yes, please specify:

No

2. A Community Member

Yes

No

Question 5.

What health services have you used previously?
e.g. Community Health, Cardiology, Diabetes

Question 6.

What do you see as high priorities in your locality?

Question 7.

What happens with the information you provide?

The information received will be treated as confidential. The feedback provided will be used to contribute toward future health service planning.

Question 8.

Would you like to participate in health services planning?

Yes

No

if yes, your contact details will be placed on the Sydney West Area Health Service Participation data base to inform you of any planned consultation processes that you may like to participate in.

How would you like to receive this information:

By Post

By e-mail