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administered by
NDSS Helpline
1800 637 700
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For Healthcare Professionals
NDSS Helpline
1800 637 700
AHW Expression of Interest
ORGANISATION DETAILS
Organisations Name
(Required)
Service Region
(Required)
Metropolitan city area
Regional centre
Rural centre
Remote service
National service / organisation
Statewide service /organisation
Region wide service /organisation
Primary Role of Organisation
(Required)
Aboriginal Controlled Health Service
National Aboriginal Community Controlled Health Organisations
Tertiary Level Hospital – Public or private
Secondary Level Hospital – Public or private
Primary Care Service – Public or Private
General Practice
Community Health – Public or private
Primary Health Network
Self Employed
Private Practice
Small rural health service
Aged Care Service
Private Clinic
Mental Health Service / Facility
Day Procedure Unit
Employee Overview (EFT):
Do you employee Aboriginal and/or Torres Strait Islander Healthcare Workers?
Yes
No
Prefer not to say
Coordinator/Manager Contact Name
Position Title
Organisation Address
Email
Phone
ORGANISATION MANAGER / CLINCIAL LEAD TO COMPLETE
Question 1
Please outline your reasons for applying to run the Foot Forward Diabetes Foot Check Training
Question 2
Please provide an outline of how your organisation intends to deliver and support the running of the Foot Forward Diabetes Foot Check Training
PROPOSED FOOT FORWARD DIABETES FOOT CHECK FACILITATOR DETAILS
Trainer 1
Name of Trainer
(Required)
Primary Clinical Discipline
Current Position
Email
(Required)
Phone
(Required)
Aboriginal or Torres Strait Islander origin?
Yes
No
Prefer not to say
Experience/knowledge in diabetes related foot disease
Experience in delivering health education programs (brief)
Cultural Training Completed or Recognition of Prior Learning/Experience eligible
Yes
No
Please provide any other comments that support appropriateness to the delivery of this program
Do you want to add another trainer (yes/no)?
Yes
No
Trainer 2
Name of Trainer
(Required)
Primary Clinical Discipline
Current Position
Email
(Required)
Phone
(Required)
Aboriginal or Torres Strait Islander origin?
Yes
No
Prefer not to say
Experience/knowledge in diabetes related foot disease
Experience in delivering health education programs (brief)
Cultural Training Completed or Recognition of Prior Learning/Experience eligible
Yes
No
Please provide any other comments that support appropriateness to the delivery of this program
Do you want to add another trainer (yes/no)?
Yes
No
Trainer 3
Name of Trainer
(Required)
Primary Clinical Discipline
Current Position
Email
(Required)
Phone
(Required)
Aboriginal or Torres Strait Islander origin?
Yes
No
Prefer not to say
Experience/knowledge in diabetes related foot disease
Experience in delivering health education programs (brief)
Cultural Training Completed or Recognition of Prior Learning/Experience eligible
Yes
No
Please provide any other comments that support appropriateness to the delivery of this program
Do you want to add another trainer (yes/no)?
Yes
No
Trainer 4
Name of Trainer
(Required)
Primary Clinical Discipline
Current Position
Email
(Required)
Phone
(Required)
Aboriginal or Torres Strait Islander origin?
Yes
No
Prefer not to say
Experience/knowledge in diabetes related foot disease
Experience in delivering health education programs (brief)
Cultural Training Completed or Recognition of Prior Learning/Experience eligible
Yes
No
Please provide any other comments that support appropriateness to the delivery of this program
Do you want to add another trainer (yes/no)?
Yes
No
Trainer 5
Name of Trainer
(Required)
Primary Clinical Discipline
Current Position
Email
(Required)
Phone
(Required)
Aboriginal or Torres Strait Islander origin?
Yes
No
Prefer not to say
Experience/knowledge in diabetes related foot disease
Experience in delivering health education programs (brief)
Cultural Training Completed or Recognition of Prior Learning/Experience eligible
Yes
No
Please provide any other comments that support appropriateness to the delivery of this program
