NRS Stakeholder Reference Panel - Application Form Survey

The National Relay Service (NRS) is a telephone solution for people who are deaf or have hearing impairment or speech impairment. It is a Commonwealth Government initiative funded through a levy on Telecommunication providers.

The NRS Stakeholder Reference Panel (NRS-SRP) is a pool of people who are interested in the NRS and represent a range of experience and views.

Thank you for considering joining the NRS Stakeholder Reference Panel. Please complete the application form below.

Should your circumstances change and/or you no longer wish to participate please contact the NRS Helpdesk: helpdesk@relayservice.com.au or 1800 555 660.

Questions marked with * are compulsory.

Please do not leave any boxes blank in Q.1. Instead, please insert NA (not applicable).

Question Title

* 1. Contact details (this information will be kept confidential by NRS):

Name: *

Organisation: *

Address 1: *

Address 2:

Suburb/Town: *

State: *

Post Code: *

Email Address: *

Mobile or main phone: *

Question Title

* 2. Are you of Aboriginal or Torres Strait Islander origin?

Yes, Aboriginal

Yes, Torres Strait Islander

No, none of the above

Question Title

* 3. What is your gender?

Female

Male

Question Title

* 4. What is your age?

Under 18 years

19-30 yrs

31-40 yrs

41-50 yrs

51-60 yrs

61-70 yrs

71-80 yrs

81 plus

Prefer not to say

Question Title

* 5. Which of the following best describes your situation? (tick all that apply)

I have a hearing impairment (see also Q.6)

I have a speech/communication impairment

I am a member of the Deaf community

I have complex communication needs that relate to my disabilities

I am a family member of someone from one of the above groups

I have clients/patients with hearing loss

I have clients/patients with speech loss

I work in a business/government agency

Other (please specify)

Question Title

* 6. My hearing impairment was acquired when I was:

0-19 yrs

20-39 yrs

40-59 yrs

60+

I was born with a hearing impairment

Question Title

* 7. Which of the following describes your employment, if applicable? (tick all that apply)

I work in primary health care

I work in the disability sector

I work in aged care

I work in telecommunications or for a phone provider

I work for an equipment provider

I work in a contact centre

I work for an emergency service

I work in a government agency

I work in a large business

I work in an SME

I work in a volunteer capacity

Other (please specify)

Question Title

* 8. I work in the education sector

Yes