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

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