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 a RACGP member and would like to claim 5 hours for participating in this Peer Group Learning Accredited Activity, please provide us with your RACGP membership number.

Note: RACGP members who attend at least 4 sessions will be eligible to receive 5- hours for a Reviewing Performance activity under the Peer-Group Learning model. RACGP members who attend fewer than 4 sessions, will receive an attendance certificate to self-claim their hours.

Question Title

* 15. If you are an ACRRM member and would like to claim hours for participating in this Case Discussion Activity (Performance Review Category), please provide us with your ACRRM membership number.

T