Expression of interest - Virtual ECHO Immersion Training

Primary contact and team information

When you and your team are ready to become an ECHO Replication Partner, please complete this form to schedule your team's attendance at Virtual ECHO Immersion Training and associated Partner Liaison meetings.

If you have any questions regarding the process of becoming an ECHO Replication Partner through CHQ's Project ECHO Superhub, please visit our website or email ECHO.CHQ@health.qld.gov.au

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* Personal Information

Full Name

Organisation

Postal Code

Country

Email Address

Mobile Number

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* Profession

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* Please specify your professional role

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* Anticipated ECHO team role

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* How many members of your team do you anticipate will attend Immersion? Remember you need to send at least 3 team members, preferably including Program Lead, a content expert who could fill the role of Facilitator, and Network Coordinator:

Expression of interest - Virtual ECHO Immersion Training

Primary contact and team information

Question Title

* Personal Information

Question Title

* Profession

Question Title

* Please specify your professional role

Question Title

* Anticipated ECHO team role

Question Title

* How many members of your team do you anticipate will attend Immersion? Remember you need to send at least 3 team members, preferably including Program Lead, a content expert who could fill the role of Facilitator, and Network Coordinator:

Question Title

* Please list the names and contact emails of known attendees from your team: