Palliative Care ECHO Network Enrolment Form

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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?

GP Specialist

Non- GP Specialist (please also select other and specify)

Nurse

IMG

Junior Doctor

Pharmacist

Allied Health Professional (please also select other and specify)

Other (please specify)

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* 6. Workplace name

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* 7. Workplace suburb

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* 8. Is your work location classified as:

Metropolitan SA

Regional SA

Remote SA

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* 9. Would your work environment be described as

Solo practice

Team of practitioners from the same clinical discipline

Team of practitioners of different clinical disciplines

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* 10. Do you have a patient case you would like to discuss at the network?

Yes

Unsure

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* 11. What would you like to gain from joining the Palliative Care ECHO Network?

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

Complex symptoms in advanced malignant illness

Mental health at EOL

Emergencies in Palliative Care

Symptom Management and establishing goals of care in end stage organ failure

Agitation, delirium and terminal sedation

Complex Bereavement

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* 13. How did you hear about the Palliative Care ECHO Network?

SAPMEA

Adelaide PHN

Country SA PHN

SA Health / RSS

GP Integration Unit

Direct email invitation

Social media

Word of mouth

Other (please specify)

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* 14. 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 session 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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* 15. 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 session attended.

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

Yes

No, I am already subscribed

No, I am not interested

Palliative Care ECHO Network Enrolment Form

Question Title

* 1. First name

Question Title

* 2. Last name

Question Title

* 3. Email address

Question Title

* 4. Mobile number

Question Title

* 5. What is your profession?

Question Title

* 6. Workplace name

Question Title

* 7. Workplace suburb

Question Title

* 8. Is your work location classified as:

Question Title

* 9. Would your work environment be described as

Question Title

* 10. Do you have a patient case you would like to discuss at the network?

Question Title

* 11. What would you like to gain from joining the Palliative Care ECHO Network?

Question Title

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

Question Title

* 13. How did you hear about the Palliative Care ECHO Network?

Question Title

* 14. 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 session 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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* 15. 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 session attended.

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

* 15. 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 session attended.