UOW Health Innovations Research Centre

UOW Health Innovations Research Centre - Consumer Sign Up Form

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

UOW Health Innovations Research Centre 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 are having trouble completing this form, or would like a hardcopy to fill out, please email uowhi-network@uow.edu.au

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
Section 2

The following questions are to help us direct the most appropriate opportunites to you
What is your sex recorded at birth (i.e. the sex on your original birth certificate)?
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 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) 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) 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 I am a carer of a person with a health condition (please specify in 'Other') Alcohol and other drug/substance use 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 Documents printed out Hearing Loop Wheelchair Access Language interpreter (if English is not your first language) or other cultural support 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? Yes No
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.
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/

This information will be securely stored, and will only be accessed by relevant members of the UOW Health Innovations Research Centre team to contact you regarding opportunities. We will not share your information with anyone outside our organisation unless we have your permission.

UOW Health Innovations Research Centre - Consumer Sign Up Form

UOW Health Innovations Research Centre - Consumer Sign Up Form

Section 2

Data Collection Statement