Palliative Care ECHO Series 2 - Enrolment Form

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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?

GP Specialist

Non- GP Specialist (please also select other and specify)

Nurse

IMG

Junior Doctor

Pharmacist

Allied Health Professional (please also select other and specify)

Other (please specify)

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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:

Metropolitan SA

Regional SA

Remote SA

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

Yes

Unsure

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* 10. What would you like to gain from joining the Palliative Care ECHO Network?

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* 11. For each of the curriculum topics listed below, please share your learning needs and requests for specific focus areas:

Cancer and non-cancer pain management

Emergencies in palliative Care

Indications and symptom management approaching last days of life

Voluntary Assisted Dying (VAD)

Dying at home & post-death management

Spirituality, cultural and inclusive considerations in death and dying

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* 12. How did you hear about the Palliative Care ECHO Network?

SAPMEA

Adelaide PHN

Country SA PHN

SA Health / RSS

GP Integration Unit

Direct email invitation

Social media

Word of mouth

Other (please specify)

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* 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 session attended.

GPs presenting a case for discussion, will receive 1 CPD hour under the Measuring Outcomes category (to be self-claimed)

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* 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 session attended.

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* 15. Would you like to subscribe to our fortnightly newsletter?

Yes

No, I am already subscribed

No, I am not interested

Palliative Care ECHO Series 2 - Enrolment Form

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

Question Title

* 10. What would you like to gain from joining the Palliative Care ECHO Network?

Question Title

* 11. For each of the curriculum topics listed below, please share your learning needs and requests for specific focus areas:

Question Title

* 12. How did you hear about the Palliative Care ECHO Network?

Question Title

* 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 session attended.GPs presenting a case for discussion, will receive 1 CPD hour under the Measuring Outcomes category (to be self-claimed)

Question Title

* 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 session attended.

Question Title

* 15. Would you like to subscribe to our fortnightly newsletter?

* 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 session attended.