THE AUSTRALIAN COUNCIL ON HEALTHCARE STANDARDS

THE AUSTRALIAN COUNCIL ON HEALTHCARE STANDARDS
ACHS SURVEYOR APPLICATION FORM
PERSONAL DETAILS – (please use block letters)
I
(Title) - (Given names) - (Last name)
wish to be considered as an ACHS Surveyor.
Present position(s)/appointment(s):
Workplace address:
Post Code:
Telephone ( ) E-mail
Fax ( ) Mobile
Residential address:
Post Code:
Telephone ( ) E-mail
Fax ( ) Mobile
Preferred address for correspondence (please indicate) ____ Home
____ Work
____ Other
Last reviewed 29/111/11
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THE AUSTRALIAN COUNCIL ON HEALTHCARE STANDARDS
ACHS SURVEYOR APPLICATION FORM
Referees:
Please give the names and addresses of two referees.
The first referee should be the applicant’s next most senior work colleague. If the applicant
is a CEO then the referee should be the Chairman of the Board.
The second referee should be a health care professional (a current ACHS Surveyor is
preferred).
1.
2.
PLEASE INCLUDE WITH THIS APPLICATION THE FOLLOWING:
(1) CURRENT CURRICULUM VITAE
(2) POSITION DESCRIPTION
(3) LETTER ADDRESSING THE SELECTION CRITERIA.
I, the applicant, have read the enclosed list of responsibilities/commitments required of
ACHS surveyors and I am able to comply if selected as a surveyor.
Applicant
Date
(General Manager, Chief Executive
Officer of Hospital/Area Health
Service/Region)
Date
Please return this application to:
Executive Director – Customer Services
The Australian Council on Healthcare Standards
5 Macarthur Street ULTIMO NSW 2007
Last reviewed 29/111/11
C:\Users\mbagnato\AppData\Local\Microsoft\Windows\Temporary Internet Files\Content.Outlook\JZUDIP17\Surveyor_App