Registration of Interest

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ASPREN Registration Form

Practice Name:

Practice Address:

Practice Address Suburb:

Practice State:

Practice Postcode:

Mailing address same as practice address

Mailing Address:

Mailing Address Suburb:

Mailing Address State:

Mailing Address Postcode:

Phone Number:

Fax Number:

Practice Email:

A copy of this form will be emailed to this email address upon completion.

Practice Manager:

Primary Health Network:

Practice Software: Best Practice Medical Director ZedMed Other

Please specify...

Reporting Method: Paper Web Data Extraction Tool - for more information please contact the team at aspren@adelaide.edu.au Yet to be advised upon sign up

What category would you place the practice in: City/Metro Rural Remote Other

Please specify...

Are there any special clinics offered at the practice: No Yes

Please specify...

What are the average number of consultations at the practice per week:

Number of external consultations:

Do you see the following age groups in General Practice: < 5 years 5 - 14 years 15 - 24 years 25 - 44 years 45 - 64 years > 65 years All age groups

Is there predominantly one age group that is seen at the practice: No Yes

Please specify...

How did you hear about ASPREN: Information received in mail Presenting or exhibiting at a conference Word of mouth Other

Please specify...

Do you give ASPREN permission to acknowledge your practice, and the associated reporters, on our public website aspren.com.au and our reporting MIS website at aspren.dmac.adelaide.edu.au: No Yes

GP Details: Please provide details for all GPs or nurse practitioners at the practice that will be participating in ASPREN

GP or nurse practitioner Information

Position GP Nurse Other

Please specify...

Title:

First Name

Last Name

RACGP or ACRRM Number

Email Address (see additional information below)

Reporting Level

See below in Additional Information for description of reporting levels Silver Gold Platinum To be decided after training

Average number of patients seen each week:

Would you like to receive reports from national and jurisdictional public health communicable disease surveillance systems? Yes No

Additional Information

Reporting Levels

Silver - reporting Influenza Like Illness (ILI) only
Gold - reporting ILI, Gastro, Chicken Pox and Shingles
Platinum - reporting ILI, Gastro, Chicken Pox, Shingles and Swab Testing 20% of ILI patients

CPD Points Allocation

It is important that the GPs RACGP or ACRRM numbers are provided to ensure their points are allocated

Email Address

CPD point accrual information, payment information and other important reporting reminders are sent to reporters via email. Therefore it is imperative that we have a direct email address for participating reporters - not a generic practice email.

ASPREN Training

Upon receiving the completed form an ASPREN team member will be in contact with the practice manager to arrange a day and time for the participating GPs and/or practice managers to receive ASPREN training.

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