Regional Network - Request to join.

Please complete this form in order to:
1) nominate a regional professional society, college or workforce development organisation to be added to the network or
2) if you are an individual who would like to be kept informed about activities of the network, you can start at question 8.
 
 
1. Name of the Organisation:
 
 
 
2. Please indicate which of the following best describes the nature of the organisation
 
A professional society, representing health care professionals
A medical or health professional College
An organisation which provides professional or workforce development to health care workers
Other
 
Other, please specify:
 
 
 
3. What conditions are covered by your organisation?
Tick all that apply.
 
HIV
Viral Hepatitis (Hepatitis B or Hepatitis C)
Sexual Health (sexually transmissible infections, venereology)
Reproductive Health
Public Health
Addiction medicine, harm minimisation, harm reduction
Infectious diseases, tropical medicine
Mental health, psychology, counselling, support
Paediatrics
Other
 
Other, please specify:
 
 
 
4. Jurisdiction, Country or Region covered by your organisation:
 
 
 
5.Organisation website address:
 
 
 
6.Your role in the organisation:
 
 
 
7. Please indicate where your organisation would generally be placed in relation to gross national income for future discussions relating to a fee for accessing the Regional Network:
 
High income
Upper Middle Income
Lower Middle income
Lower income
We are regional and cover a range of countries
Don’t know
 
 
8. Full Name:
 
 
 
9. Email address:
 
 
 
10. Phone or mobile number:
 
 
 
11. What is you main professional role?
Clinician, Clinical educator, Dentist, Administrator etc?
 
 
 
12. What conditions do you mainly work in?
 
HIV
Viral hepatitis (hepatitis B or Hepatitis C)
Sexual Health (sexually transmissible infections, venereology)
Reproductive health
Public health
Addiction medicine, harm minimisation, harm reduction
Infectious diseases, tropical medicine
Mental health, psychology, counselling, support
Paediatrics
Other
 
Other, please specify: