Clinical Quality Registries Special Interest Group (CQR SIG) application form Clinical Quality Registries Special Interest Group (CQR SIG) Membership Application Your personal details. Title Name Name First Name First Name Last Name Last Name Work Address City State Post Code Country Work Phone Email Current Position Title Which of the following professional categories bestdescribes your connection to the registry sector? (Pleaseselect One option only) Project Manager Project Officer/ Coordinator Registry Manager Data Manager Data Custodian Academic Researcher Clinician Other (please specify) Select the option that best reflects your involvement with registries: Planning stage Currently involved Not directly involved Other (please specify) Please list the name of the organisation/ peak body that you are employed by (i.e. Monash University, Australian Orthopaedic Association, SAHMRI, RACS, etc). Please indicate which registry/ registries you are currently working in (or with) (Name/ Abbreviation and URL if possible). If none, please write “none”. What skills or expertise do you have which supports the CQR SIG? What are your areas of interest in the registry sector? Would you like to be added to our monthly ACTA newsletter to be informed of sector news and events? Yes No Submit If you are human, leave this field blank. Δ
