Registration Form | Hepatitis C for A&TSIHW/HPs
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1.
Which training session are you registering for?
(Required.)
National Online - Nov 27/Dec 4 2020
NT/WA Online - June 04, June 11 2021
NSW/ACT/VIC/TAS Online - July 15, July 22 2021
QLD/SA Online - July 16, July 23 2021
National Online - November 12 2021
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2.
First Name
(Required.)
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3.
Last Name
(Required.)
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4.
Organisation name
(Required.)
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5.
Which of the following describes your main service setting?
(Required.)
Aboriginal Community Controlled Health Organisation
Aboriginal Medical Service
Other (please write)
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6.
City
(Required.)
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7.
State/territory
(Required.)
QLD
NSW
ACT
VIC
TAS
NT
SA
WA
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8.
Post code
(Required.)
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9.
Mobile phone or best contact number
(Required.)
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10.
Email address
(Required.)
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11.
What would you describe as your main profession?
(Required.)
Aboriginal and Torres Strait Islander Health Worker/Health Practitioner
Aboriginal and Torres Strait Islander Community Worker
Health Promotion/Educationalist
Nurse Practitioner
Midwife
Practice Nurse
Allied Health Professional
General Practitioner
Nursing – other
Social Worker
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12.
What is your position title?
(Required.)
13.
Do you identify as Aboriginal and/or Torres Strait Islander?
Yes, Aboriginal
Yes, Torres Strait Islander
Yes, Aboriginal and Torres Strait Islander
No
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14.
Would you consent to being approached to take part in a small group discussion after the course
to assist us in improving the course? (Compensation of $100 will be provided. Further details will be provided closer to the date of the course)
(Required.)
Yes
No
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15.
Do you have access to Zoom?
(Required.)
Yes
No
