UOW Consumer and Community Research Network Sign Up Form

Completing this form will sign you up as a member of the UOW Consumer & Community Research Network.

UOW will not disclose your information to anyone outside our organisation without your consent.

Your information is collected in line with our privacy policy. For further information about UOW's commitment to protecting your privacy, please visit: https://www.uow.edu.au/privacy/

If you:
- Find the form difficult to complete
- Prefer a paper copy
- Use assistive technology and need an alternative format
Please contact us at uowhi-network@uow.edu.au.

We are here to help and will do our best to meet your needs.

First name
Last name
Preferred phone number
Postcode of residence
What is your age?
Email
What is your preferred form of contact?

What is your preferred form of contact? Email Phone Other (please specify)
Preferred form of contact - Other
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The following questions are to help us direct the most appropriate opportunites to you
[HIDDEN] What is your sex recorded at birth (i.e. the sex on your original birth certificate)?
[HIDDEN] Sex recorded at birth - Other
How do you describe your gender?
Gender - Other
What is the main language you speak at home?

What is the main language you speak at home? English Arabic Italian Macedonian Mandarin Other (please specify)
Language - Other
Please indicate if you have an interest in, personal experience with, or are a caregiver for someone in the following health areas:
You can select more than one option.

Please indicate if you have an interest in, personal experience with, or are a caregiver for someone in the following health areas: You can select more than one option. Heart disease (High Blood Pressure, Heart Attack, Heart Failure) Antimicrobial Resistance, Infections or use of Antibiotics Cancer (Solid tumours, Haematological Cancers) Chronic pain Bowel Conditions (Irritable Bowel Syndrome, Inflammatory Bowel Disease) Diabetes Lung Disease (Emphysema, Fibrosis) Chronic Kidney Disease Asthma Mental Illness (Depression, Anxiety or other diagnosed conditions) Cardiovascular disease (Stroke, Mini-stroke) Neurological disorders (Motor Neurone Disease, Multiple Sclerosis, Parkinson's Disease) Food Allergies and Intolerances Dementia or Cognitive Impairment I have a child with a health condition (please specify in "Other") I am an athlete or very physically active individual Alcohol and other drug/substance use Aged Persons Carer Carer of person with disability or chronic illness (please specify in "Other") Parent to a child under 18 Other (please specify)
Health Areas - Other
What role/s are you interested in being involved in?
You can select more than one option.

What role/s are you interested in being involved in? You can select more than one option. Informing – being informed by researchers. Information provided may be about health conditions, rights and responsibilities, health services or programs. This may be in the form of brochures, videos, community stalls or websites Consulting – giving us feedback. This could be about services, experiences, resources or programs. Feedback may be via conversations, focus groups or surveys. Advising – providing advice about what is working and not working, and plans for the future. Topics may include research priorities and how to recruit participants and disseminate results via workshops or forums. Collaborating – being partners in shared decision making about your care and health services via committees, workshops, forums and working groups. Leading – working, learning and reflecting together to plan and deliver activities, resources or services. This can be referred to as ’consumer-led’. Participating in a study - trialling a new program, service, product or treatment type. This allows researchers to collect data on new ways to deliver health care or methods of treating certain health conditions. All of the above
Do you need any of the access requirements below?
You can select more than one option.

Do you need any of the access requirements below? You can select more than one option. Accessible parking Assistance Dog Audio support Captioning or live transcription Documents printed out Hearing Loop Large print or alternative formats Wheelchair access Language interpreter or cultural support Quiet space or low-sensory attenance Remote participation Support person or carer attendance Flexible timing or breaks None of the above Other (please specify)
Accessibility - Other
Would you like to sign up to receive our newsletter via email?

Would you like to sign up to receive our newsletter via email? Health Innovations Newsletter Molecular Horizons Newsletter Both None
Do you give us permission to distribute opportunities to you, relevant to your health condition or expertise?

Do you give us permission to distribute opportunities to you, relevant to your health condition or expertise? Yes No
Is there anything else you'd like to share with us? This could include feedback or suggestions.
How did you hear about the UOW Consumer and Community Research Network?
Data Collection Statement

The information you provide on this form is collected in line with our privacy policy. For further information about UOW's commitment to protecting your privacy, please visit: https://www.uow.edu.au/privacy/

Your consumer details and information provided will only be accessed by authorised and approved staff to contact you for any research projects and opportunities that may be relevant to you. No further information will be provided without your permission.

UOW Consumer and Community Research Network Sign Up Form

UOW Consumer and Community Research Network Sign Up Form

Section 2

Data Collection Statement