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.

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* 1. First name

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* 2. Last name

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* 3. Email address

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* 4. Mobile number

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* 5. What is your profession?

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* 6. Primary workplace name

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* 7. Primary workplace suburb/town

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* 8. Do you practise or provide outreach services in rural or regional locations?
Please note that enrolment in the COPD ECHO Program is restricted to health practitioners who provide services to regional/rural locations only.

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* 9. If you are a GP/GP registrar, which option best describes your primary place of work:

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* 10. Do you have a patient case you would like to discuss at the network?

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* 11. What would you like to gain from joining the COPD ECHO Network?

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* 12. For each of the curriculum topics listed below, please share your learning needs and requests for specific focus areas:

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* 13. Please rate your awareness and use of the Lung Foundation Australia COPD-X Guidelines

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* 14. Are you currently involved in any QI PIP activities to improve your practice and management of COPD?

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* 15. How did you hear about the COPD ECHO Network?

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* 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.

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* 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.

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