PATSI Meeting: Tuesday 19 March, 1pm - 3:00pm
Deceased Resident File Audit Project
Are we there yet?

When you complete the details below you will be registered to attend.

TARGET AUDIENCE: Specifically for Managers, CNCs and Palliative Approach Link Nurses committed to the ongoing implementation of the palliative approach in Residential Aged Care Facilities.

We will contact you via email to confirm your registration and to provide further details (map to the venue, parking, etc) approximately 1 week prior to the meeting date.

Thank you.

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* 1. What is your name?

First name

Last name

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* 2. Where do you work?

Name of service/organisation

Street address

Suburb

Post code

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* 3. What type of service do you work for?

Aged care

Other (please specify)

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* 4. Which best describes your profession?

Administration

Registered nurse (RN)

Trainer/educator

Facility Manager

Enrolled Nurse (EN)

Other (please specify)

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* 5. What is your role/title (e.g. Team Leader, CNC, Unit Manager, other)?

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* 6. Have you completed the Palliative Approach Toolkit Training?

Yes, with Decision Assist

Yes, with SMRPCC or a service other than Decision Assist

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* 7. If you have not completed the toolkit training is there a trained link nurse in your facility who has completed the PA Toolkit training? If yes, please provide their name.

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* 8. At what email address would you like to be contacted?

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* 9. At what telephone number do you prefer to be contacted?

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* 10. Have you undertaken a PEPA Placement?

Yes

If yes, what year was it completed?

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* 11. Would you like to receive the SMRPCC's monthly email update?

Yes, please email to the address provided at Q.8

No, thank you

Yes, please email to:

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* 12. If you work in an aged care facility please provide the name and email address of your CNC

First name (of CNC)

Surname (of CNC)

Email address (of CNC)

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* 13. To assist us in facilitating further education and training opportunities for aged care staff we would appreciate the contact details of your facility's Education & Training Officer.

First name

Surname

Email address