Practice enrolment form

Practice name *

Name *

First

Last

Email *

Which of the following best describes your main role? *

Other role (please specify)

From the following options, please specify if your practice is currently or has previously:

Conducted a clinical audit of practice software to identify eligible hepatitis C patients for recall
Developed and completed a Quality Improvement Plan for hepatitis C
Used a clinical audit tool to complete a clinical case finding audit for hepatitis C
Developed a system to recall patients for testing, treatment and/or monitoring of hepatitis C

Please describe any resources or guidelines your practice has to promote hepatitis C testing, treatment and support for clinic staff.

Please describe any resources or guidelines your practice has to promote hepatitis C testing, treatment and support for patients.

Please describe any resources or guidelines your practice has to promote hepatitis C testing, treatment and support for First Nations peoples.

Please describe any resources or guidelines your practice has to promote hepatitis C testing, treatment and support for patients from CALD backgrounds.

Why is your practice interested in participating in Beyond the C? Select all that apply *

Other (please specify)

Is the practice accredited under the National General Practice Accreditation (NGPA) Scheme? *

Yes
No

Is the practice(s) registered for Practice Incentives Program Quality Improvement (PIP QI)? *

Yes
No

What Electronic Medical Software System does your practice use? *

What Data Extraction Tool does your practice use?

Beyond the C

Practice Enrolment Form