Full Name
*
First Name
Last Name
Email
*
example@example.com
ACEM Membership Number (If applicable)
What is your primary professional classification?
*
FACEM
FACEM Trainee
Other ACEM Trainee
ACEM Certificant
ACEM Diplomate/Advanced Diplomate
Allied Health Professional
Medical Officer/Intern
Medical Administrator/Clerical Staff
Nursing Staff
Other Speciality Consultant
Other Speciality Trainee
Paramedic
Research Staff
Other
Are you any of the following?
*
Director of Emergency Medicine (DEM)
Director of Emergency Medicine Research (DEMR)
ED Data Manager (or equivalent)
ED Research Coordinator (or equivalent)
None of the above
Other
Do you have a post-graduate research qualification?
*
Masters
MD
PhD
None of the above
Other
What is your country/state of residence?
*
Aotearoa New Zealand
Australian Capital Territory
New South Wales
Northern Territory
Queensland
South Australia
Tasmania
Victoria
Western Australia
Other
Country/State
*
Australian Capital Territory
New South Wales
New Zealand
Northern Territory
Queensland
South Australia
Tasmania
Victoria
Western Australia
What is your city/town of residence?
*
Street Address
Street Address Line 2
State/Town
Postal / Zip Code
What is your primary place of employment?
*
(e.g. Auckland City Hospital)
What is your primary area of research interest?
*
What other research networks are you a member of, if any?
ACEM Emergency Department Epidemiology Network
Australasian Society for Infectious Diseases Clinical Research Network
Australasian Stroke Trials Network Australia & New Zealand
Australian & New Zealand College of Anaesthetists Clinical Trials Network
Australian & New Zealand Intensive Care Society Clinical Trials Group
Australian Paediatric Research Network
New Zealand Emergency Medicine Network
Paediatric Research in Emergency Departments International Collaborative (PREDICT)
Spinal Cord Injury Network
Other
What other Colleges/professional organisations are you associated with, if any?
Australasian College of Dermatologists (ACD)
Australasian College of Anaesthetists (ANZCA)
Australian College of Nursing (ACN)
Australian College of Nurse Practitioners (ACNP)
Australian College of Critical Care Nurses (ACCCN)
Australian College of Rural and Remote Medicine (ACRRM)
Australasian College of Sports and Exercise Physicians (ACSEP)
College of Emergency Nursing Australasia (CENA)
College of Intensive Care Medicine (CICM)
College of Nurses Aotearoa (NZ)
Nurse Practitioners New Zealand (NPNZ)
Australasian College of Paramedic Practitioners (ACPP)
Royal Australian and New Zealand College of Ophthalmologists (RANZCO)
Royal Australian and New Zealand College of Psychiatrists (RANZCP)
Royal Australian College of General Practitioners (RACGP)
Royal Australasian College of Obstetricians & Gynaecologists (RANZCOG)
Royal Australasian College of Medical Administrators (RACMA)
Royal Australasian College of Physicians (RACP)
Royal Australian and New Zealand College of Psychiatrists (RANZCP)
Royal Australasian College of Surgeons (RACS)
Royal Australasian College of Radiologists (RANZCR)
Royal College of Pathologists of Australia (RCPA)
Royal New Zealand College of General Practitioners (RNZCGP)
Other
Would you like to receive news on the EMCTN?
*
Yes
No
By submitting I agree to receive news of CTN activities and actively contribute to the Network.
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