COPD Telehealth: book your session Date of Telehealth session * 28th March 2018, 1.00pm-2.00pm Date of registration (dd/mm/yyyy) * First name * Last name * Gender * Female Male Other Are you Aboriginal or Torres Strait Islander? * Yes No Your profession * Place of work * Department or Health Service area (if applicable) Region * The Great Southern The Wheatbelt The Goldfields The Midwest The Southwest The Pilbara The Kimberley Email * Phone * Do you work with Aboriginal patients? * Yes No Do you work with culturally and linguistically diverse patients? * Yes No Will other people be linking into the session from your site? * Yes No If yes, please indicate the approximate number of participants Would you like to be contacted for other professional development opportunities also offered by the Asthma Foundation? * Yes No Telehealth PD Pre-Evaluation. Please complete the following section to complete your registration. To ensure your responses are anonymous, please complete the following code: First 3 letters of your father's name: * If your fathers name is David, you will put DAV. Day and month of your birthday in numbers: * E.g. 4th of September will be 0409 How would you rate your current knowledge on the topic being presented at your upcoming session? * 1 - low 2 3 4 5 - high How would you rate your current confidence on the topic being presented at your upcoming session? * 1- low 2 3 4 5 - high How confident are you in applying your current knowledge on the topic into your practice? * 1 - low 2 3 4 5 - high How would you rate your current knowledge on Asthma? * 1 - low 2 3 4 5 - high How would you rate your current knowledge on COPD? * 1 - low 2 3 4 5 - high How would you rate your confidence to prevent, treat, and manage (including supporting consumers to self manage) asthma & COPD as part of your everyday work role? * 1 - low 2 3 4 5 - high How would you rate your capacity to prevent, treat and manage (including supporting consumers to self manage) asthma & COPD as part of your everyday work role? * 1 - low 2 3 4 5 - high How would rate your knowledge of seeking education and support via Telehealth for consumers in your area with asthma & COPD? * 1 - low 2 3 4 5 - high reCAPTCHA Submit If you are human, leave this field blank.
