RACGP Qld Faculty Declaration of interests questionnaire

Name

First

Last

Address

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

Email

Mobile phone

State electorate

Federal electorate

What best describes your work as a GP? You can pick multiple.

For GP owners, what is the name of your clinic/s?

For GP academics, what is the name of your primary institution?

Other than RACGP, do you hold any memberships to professional bodies?

Examples would be AMA etc.

Other memberships

Please list any other professional memberships that might be relevant

Do you have any other paid or unpaid positions that might be relevant?

E.g. Board memberships, clinical councils etc.

Please note any other paid or unpaid positions that might be relevant

Do you have any other financial interests that might be relevant?

Examples would be shareholdings in medical education companies etc.

Please briefly list any other financial interests that might be relevant

Do you have any personal relationships that might be considered relevant/conflicted?

E.g. are you closely related to, or have a significant relationship with, a fellow Council member or other medical leader.

Please note any relevant personal relationships that might be relevant.

Which areas of GP are of interest to you from an advocacy point of view?

Is there anything else that you would like to add or might be helpful to direct our stakeholder engagement?