COPD ECHO Network Enrolment Form This is a multi-disciplinary program open to all healthcare professionals. Please provide your details and responses to the questions as relevant to your profession. Question Title * 1. First name Question Title * 2. Last name Question Title * 3. Email address Question Title * 4. Mobile number Question Title * 5. What is your profession? GP Specialist GP Registrar Non- GP Specialist (please also select other and specify) Nurse IMG Junior Doctor Pharmacist Physiotherapist Allied Health Professional (please also select other and specify) Other (please specify) Question Title * 6. Primary workplace name Question Title * 7. Primary workplace suburb/town Question Title * 8. Do you practise or provide clinical care to patients who live in regional or rural SA locations?Please note that enrolment in the COPD ECHO Program is restricted to health practitioners who provide clinical services to regional/rural patients only. Yes No Question Title * 9. If you are a GP/GP registrar, which option best describes your primary place of work: Solo practice Group practice with 2-5 GPs Group practice with 6-10 GPs Group practice with ≥11 GPs N/A Question Title * 10. Do you have a patient case you would like to discuss at the network? Yes No Unsure Question Title * 11. What would you like to gain from joining the COPD ECHO Network? Question Title * 12. For each of the curriculum topics listed below, please share your learning needs and requests for specific focus areas: Case finding and making a diagnosis Non pharmacotherapy management Pharmacotherapy management Managing exacerbations, including concurrent COVID Sleep disorders in COPD Breathlessness and end-stage COPD Question Title * 13. Please rate your awareness and use of the Lung Foundation Australia COPD-X Guidelines I am not aware of the COPD-X Guidelines I am aware of the COPD-X Guidelines but have not referred to it in my clinical practice in the past 12 months I am aware of the COPD-X Guidelines and have occasionally referred to it in my clinical practice in the past 12 months I am aware of the COPD-X Guidelines and have regularly referred to it in my clinical practice in the past 12 months Question Title * 14. Are you currently involved in any QI PIP activities to improve your practice and management of COPD? Yes No N/A Question Title * 15. How did you hear about the COPD ECHO Network? SAPMEA Country SA PHN Lung Foundation Australia SA Health GP Integration Unit Direct email invitation Social media Word of mouth Other (please specify) Question Title * 16. If you are a RACGP member and would like to claim 40 points for participating in this Peer Group Learning Accredited Activity (Reviewing Performance Category 1), please provide us with your RACGP membership number.Please note: to be eligible for the 40 points, you must attend the initiation meeting held 10 minutes prior to the start of the first session and the review meeting held 10 minutes after the end of the final session. Question Title * 17. If you are an ACRRM member and would like to claim points for participating in this Case Discussion Activity (Performance Review Category), please provide us with your ACRRM membership number. Submit response >>
