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Emergency Medicine ECHO Enrolment Form
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1.
First name
(Required.)
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2.
Last name
(Required.)
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3.
Email address
(Required.)
4.
Mobile number
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5.
What is your profession?
(Required.)
GP Specialist
Medical Specialist (non-GP)
Medical Officer
IMG
Junior Doctor/Intern
Nurse
Paramedic
Ambulance Officer
Allied Health Professional (please specify in 'Other')
Other (please specify)
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6.
Primary workplace name
(Required.)
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7.
Primary workplace suburb/town
(Required.)
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8.
Is your work location classified as:
(Required.)
Metropolitan SA
Regional SA
Rural SA
Other (please specify)
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9.
Do you have a clinical case you would like to present for discussion?
(Required.)
Yes
No
Unsure
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10.
What would you like to gain from joining the Emergency Medicine ECHO?
(Required.)
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11.
For each of the curriculum topics listed below, please share your learning needs, questions or requests for specific focus areas:
(Required.)
Managing acute intoxication / drug affected patients in the ED (July 24th)
Managing head injuries in the ED - Role of CT (August 28th)
When and how to start inotropes (September 25th)
ALS in special circumstances (October 23rd)
'Difficult' pain relief (November 27th)
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12.
How did you hear about the Emergency Medicine ECHO Program?
(Required.)
SAPMEA
RACGP or ACRRM
Social media
Colleague
Other (please specify)
13.
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 meeting attended.
GPs presenting a case for discussion, will receive 1 CPD hour under the Measuring Outcomes category (to be self-claimed)
14.
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 meeting attended.
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15.
Would you like to subscribe to our fortnightly newsletter?
(Required.)
Yes, please subscribe me
I am already subscribed
No, I am not interested
