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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?

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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:

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* 9. Would your work environment be described as

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

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* 11. What would you like to gain from joining the Cardiology 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:

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

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* 14. If you are a RACGP member and would like to claim 40 points for participating in this Peer Group Learning Accredited Activity (Reviewing Performance Category 1), please provide us with your RACGP membership number.

Note: RACGP members who attend at least 4 sessions and participate in both the planning and review meeting will be eligible to receive 40 points (Cat 1) for a Reviewing Performance activity under the Peer-Group Learning model. RACGP members who do attend fewer than 4 sessions, will still receive an attendance certificate to self-claim Cat 2 points.

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

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