AOD Harm Reduction - Rockhampton

Other information

• What state or territory do you live in?

  … Queensland New South Wales Victoria South Australia Western Australia Tasmania Northern Territory Australian Capital Territory I don't live in Australia

• The country where I live is

• The postcode of my usual workplace is:

• Line Manager's Name

• Line Manager's Position Title

• Line Manager's Email

• Company / Organisation

• What type of organisation do you work for?

  … Non-Government Organisation Queensland Health – Hospital Health Service Queensland Health - Department of Health Other State Government Department Federal Government Dept. Local Government GP Clinic or other private medical company A University or other academic institution I am a student Private company / business / PHN I am a private individual Other

• Which state Government Department do you work in?

  … Education Queensland Queensland Corrective Services Dept. of Child Safety, Youth and Women Dept. of Communities Queensland Police Service Dept. Justice and Attorney General Dept. of Housing

• Which HHS or Department do you work for?

  … Cairns and Hinterland Central Queensland Central West Children's Health Queensland Darling Downs Gold Coast Mackay Metro North Metro South North West South West Sunshine Coast Torres and Cape Townsville West Moreton Wide Bay Dept of Health

• What is the main focus of your work?

  … Alcohol and Drug Mental Health Dual Diagnosis GP / Medical General Nursing Aboriginal and Torres Strait Islander Health / SEWB Family Support Work / Child Protection Criminal Justice / Corrections Schools Adult Education Housing / Homelessness Other

• Other focus at work?

• What is your professional background / discipline?

  … Nursing Nurse Practitioner Psychology Social Work Occupational Therapy Counsellor Aboriginal and Torres Strait Islander Health Worker / SEWB Youth Worker General Support Worker Medical Officer Pharmacy Student / Volunteer Other

• To be allocated points through Australian College of Rural and Remote Medicine and The Royal Australian College of General Practitioners we require the following information. You will also need to supply your AHPRA number. The information you enter will be forwarded to MMU if you elect to become a opioid treatment prescriber.

• AHPRA Number

• Please note: To be eligible for CPD allocation, Insight requires your ACRRM and/or RACGP numbers.

• ACRRM Number

• RACGP Number

• Are you currently working in a direct treatment or frontline support role within an AOD or Mental Health service?

  yes no

• Do you identify as Aboriginal and/or Torres Strait Islander?

  yes no

• Do you identify as CALD (Culturally and Linguistically Diverse)?

  yes no

• If you have any special dietary requirements please list them here

• Do you have special access or mobility requirements that we should be aware of?

  yes no

• Please list any special access or mobility requirements that we should be aware of: