First Name

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* 1. First Name

Last name

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* 2. Last name

Email contact

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* 3. Email contact

Age

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* 4. Age

Gender

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* 5. Gender

Country of work

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* 6. Country of work

Current Hospital/workplace

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* 7. Current Hospital/workplace

Current Position and qualifications

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* 8. Current Position and qualifications

How many years postgraduate are you?

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* 9. How many years postgraduate are you?

Are you currently studying a degree?

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* 10. Are you currently studying a degree?

How many years have you worked in emergency or your current practice?

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* 11. How many years have you worked in emergency or your current practice?

Any previous toxicology experience?

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* 12. Any previous toxicology experience?

How would a toxicology course fit into your current training/practice?

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* 13. How would a toxicology course fit into your current training/practice?

Any training outside current country of residence?

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* 14. Any training outside current country of residence?

Any expectations of the toxicology course?

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* 15. Any expectations of the toxicology course?

Describe current access to toxicology education and advice. e.g. any poisons information services or consulting medical staff

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* 16. Describe current access to toxicology education and advice. e.g. any poisons information services or consulting medical staff

By registering with the course, I agree that non identifiable information from this registration and results from the course may be used for research purposes to improve the course.

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* 17. By registering with the course, I agree that non identifiable information from this registration and results from the course may be used for research purposes to improve the course.

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