Clinical Expert Panel - Application form

Personal information

Experience in rural or remote practice? *

Are you currently engaged in clinical practice? *

Do you identify as Aboriginal or Torres Strait Islander? *

Are you culturally and linguistically diverse? *

Professional information

Any restrictions on registration or practice? *

Any serious past complaints or being investigated? *

Any significant past or pending litigation? *

Do you have relevant police and working with children checks as per NSW Policy Directive PD2019_003, Working with Children Checks and Other Police Checks *

Do you have current vaccinations in accordance with NSW Policy Directive PD2018_009, Occupational Assessment, Screening and Vaccination Against Specified Infectious Diseases *

If NSW Health employee or contractor, do you have written approval from your Chief Executive to participate in the Panel? Please provide a copy of your approval if you answer yes and please obtain written approval and provide a copy to the CEC if you answer no.

Previous experience with investigations

Have you been a member of a Serious Adverse Event Review (SAER) Team?

Have you received SAER training conducted by the CEC?

Have you participated in other high-level reviews or investigations?

Have you undertaken any other training that would assist you in undertaking a review or investigation?

Have you completed any relevant studies where the principles of investigations were included in the course?

Reason for application

Referees