Committee Membership Evaluation Tool

1. Which LBHS Committee are you completing this evaluation for:

Standard 1 - Clinical Governance Standard 2 - Partnering with Consumers Standard 3 - Preventing and Controlling Infections Standard 4 - Medication Safety Standard 5 - Comprehensive Care Standard 7 - Blood Management Standard 8 - Recognising and Responding to Acute Deterioration

2. What is your role on the Committee?

Executive Chair Chair Deputy Chair Secretariat Committee Member - Metro South Health Employee Committee member - Consumer Advisor Guest

Other

5. Do you identify as Aboriginal and/or Torres Strait Islander?

No Yes; Aboriginal Yes; Torres Strait Islander Yes; both Aboriginal and Torres Strait Islander Prefer not to say

6. Do you identify with a particular cultural or ethnic background?

Yes: Please describe it here

No Prefer not to say

7. Do you speak a language other than English at home?

Yes: please include the language(s) here:

No Prefer not to say

8. Do you identify as a person living with a disability?

Yes No Prefer not to say

9. Are you the main provider of unpaid care for an older person or someone with a disability or chronic illness?

Yes No Prefer not to say

10. What is your gender?

Male Female Non-binary / genderqueer Prefer not to say

Gender identity not listed. I identify as

11. What is your sexual orientation?

Asexual Bisexual Gap Heterosexual or straight Lesbian Pansexual Queer Prefer not to answer

None of the above, please specify

12. Does the committee have representation from Consumer Advisor(s) on its membership?

Yes No - Proceed to question 16

13. Please indicate your agreement to the following statement: The contributions of Consumers Advisor(s) on the Committee are valued.

1 - Strongly disagree 2 - Disagree 3 - Neutral 4 - Agree 5 - Strongly agree

14. Please indicate your agreement to the following statement: The contributions of Consumers Advisors have resulted in positive change.

1 - Strongly disagree 2 - Disagree 3 - Neutral 4 - Agree 5 - Strongly agree

15. If positive change has been achieved, please describe what this change was in the free text box below.

If positive change has been achieved, please describe what this change was in the free text below.

16. Would you like to provide any further feedback regarding the membership of the committee?

Yes

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Introduction