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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.
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1.
First name
(Required.)
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2.
Last name
(Required.)
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3.
Email address
(Required.)
4.
Mobile number
*
5.
What is your profession?
(Required.)
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)
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6.
Primary workplace name
(Required.)
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7.
Primary workplace suburb/town
(Required.)
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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.
(Required.)
Yes
No
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9.
If you are a GP/GP registrar, which option best describes your primary place of work:
(Required.)
Solo practice
Group practice with 2-5 GPs
Group practice with 6-10 GPs
Group practice with ≥11 GPs
N/A
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10.
Do you have a patient case you would like to discuss at the network?
(Required.)
Yes
No
Unsure
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11.
What would you like to gain from joining the COPD ECHO Network?
(Required.)
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12.
For each of the curriculum topics listed below, please share your learning needs and requests for specific focus areas:
(Required.)
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
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13.
Please rate your awareness and use of the Lung Foundation Australia COPD-X Guidelines
(Required.)
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
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14.
Are you currently involved in any QI PIP activities to improve your practice and management of COPD?
(Required.)
Yes
No
N/A
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15.
How did you hear about the COPD ECHO Network?
(Required.)
SAPMEA
Country SA PHN
Lung Foundation Australia
SA Health
GP Integration Unit
Direct email invitation
Social media
Word of mouth
Other (please specify)
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.
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.
