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* 1. Your name

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* 2. Email address:

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* 3. Your Job Grade:

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* 4. Where is your country of full time employment

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* 5. Do you work clinically in more than 1 country

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* 6. What kind of work are you involved in outside the UK? (Tick all that apply)

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* 7. If you are involved in delivering care outside the UK, please select the type of work and country(ies) you work in

  Country 1 Country 2
Medical charity delivering medical care
Retrieval Medicine
Expedition medicine

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* 8. If you are involved in teaching or education outside the UK, please select the type of work and county(ies) you work in

  Country 1 Country 2
Educational programme for local organisations
Crisis resource management
Simulation courses
Ultrasound courses
Pre-hospital care education
College exam courses
Airway courses
ATLS or modification
ALS or modification
PALS or modification
MOET
Instructor course

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* 9. If you teach, what kind of teaching are you involved in?

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* 10. How many students/doctors attend your course on average?

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* 11. If you are an examiner overseas, what type of exam do you examine?

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* 12. If you are involved in service improvement / establishment, please select the type of work and country(ies) you work in

  Country 1 Country 2
Design of EM services
Service improvement work
Advisor to local government
Advisor to UN or other international organisation
Pre-hospital network development

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* 13. If you work with other societies or organisations, please select the names of the bodies you work with

  Society / Organisation
1
2
3

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* 14. For the work you are involved in are you an invitee of the host country?

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* 15. What is the source of funding?

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* 16. Have you attended any overseas conferences in EM in the past two years?

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* 17. Have you been involved as an organiser, session chair or speaker at any overseas conferences?

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* 18. The Royal College is occasionally contacted by individuals who wish to be put in contact with others who have worked in particular countries / organisations. Would you be happy for the College to pass on your contact details to interested parties in relation to your work abroad?

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