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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. Is your work location classified as:

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* 9. Do you have a clinical case you would like to present for discussion?

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* 10. What would you like to gain from joining the Emergency Medicine ECHO?

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

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* 12. How did you hear about the Emergency Medicine ECHO Program?

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* 13. If you are an RACGP member please provide your RACGP ID. 

Participants will receive 1 CPD hour under the Reviewing Performance category with RACGP for each meeting attended.

GPs presenting a case for discussion, will receive 1 CPD hour under the Measuring Outcomes category (to be self-claimed)

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* 14. If you are an ACRRM member please provide us with your ACRRM membership number.

Participants will receive 1 CPD hour under the Reviewing Performance category with ACRRM for each meeting attended.

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* 15. Would you like to subscribe to our fortnightly newsletter?

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