Expression of Interest for Consumers and Health Professionals - Multistakeholder Health Technology Assessment Reform and Implementation Reference Group - Page 1 of 5 - Australian Government Department of Health, Disability and Ageing

Page 1 of 5

About you

What is your name?

Full name (Required)

What is your email address? You will receive an acknowledgement email once you submit your response.

(Required)

Please provide your State/Territory and postcode

State or Territory (Required)

Postcode (Required)

Member type

(Required) individual consumer, patient or carer individual nominated by a consumer/patient peak body or group individual health professional (include discipline) individual nominated by a relevant health professional peak body or college

If you have been nominated by an organisation, please provide the organisation name

If you are a healthcare professional, please provide details of your discipline

Are you available to participate in 6 meetings over the next 12 months?

(Required) Yes No

Optionally, provide details about your availability