ࡱ> egd` M'bjbj 84; 21\ \ \ p XXX8L,p nZt6J```^!V!4!YYYYYYY$\hJ_NYQ\ #!!@##Y``(Z}%}%}%#j`l`Y}%#Y}%}%S0 ,)X` 3aXE$vU8Y>Z0nZV `$d`p)X`\ )X"LP"6}%",")"""YY%^"""nZ####p p p 4$p p p 4p p p   REGISTRATION OF INTEREST TO JOIN PCOC INFORMATION NETWORK Specialist palliative care services are invited to register their potential interest in participating in the quality and outcomes data collection initiative which has been established as a national collaboration commencing from early 2006. This collaboration is known as PCOC (Palliative Care Outcomes Collaboration). Additional information about PCOC is available on the PCOC web site, or by contacting PCOC on (02) 4221 4411. In order to establish an adequate list of organisations with an interest in PCOC and to begin to develop a profile of potential participants, we ask that you complete a Registration of Interest form. Completing this form does not put your organisation under any obligation for future participation. However, it does ensure that your organisation will be kept up to date with developments as these happen and that you will be invited to participate as PCOC goes live. Name of Palliative Care Service  FORMTEXT       Location of Service (eg: rural NSW/Riverina District, Metropolitan Adelaide, Townsville and environs, Gippsland Victoria etc)  FORMTEXT       Palliative Care Service Description - please tick as many as apply to your service Designated inpatient beds/unit  FORMDROPDOWN  Medical consultancy/liaison service  FORMDROPDOWN  Nursing consultancy/liaison service  FORMDROPDOWN  Community/home support service  FORMDROPDOWN  Ambulatory/outpatient symptom clinic  FORMDROPDOWN  Day Centre  FORMDROPDOWN  Other IF designated inpatient beds: Number of beds  FORMTEXT       IF  community/home support: Average number of clients per month  FORMTEXT       IF  ambulatory/outpatient clinic: Average number of clients per month  FORMTEXT       Contact Person:  FORMTEXT       Position in Organisation:  F<@  * 8   $ ͱ͟ygͱUGh_/CJOJQJ^JaJ#h2ph_/5CJOJQJ^JaJ#jhqJCJOJQJU^JaJ/jhE h CJOJQJU^JaJhE CJOJQJ^JaJ#jhE CJOJQJU^JaJh_/5CJOJQJ^JaJhqJhqJOJQJ^J h2ph_/CJOJQJ^JaJ#h2ph_/5CJOJQJ^JaJhuD5CJOJQJ^JaJ>?@    6 8  X gdCS X dhgdCS %dhgd_/ $ %a$gd+Y$a$gdqJ %gd_/ $ %a$gd_/&'L'$ & ( 2 4 : l  !#GHսլygUG/G/jhE h CJOJQJU^JaJhE CJOJQJ^JaJ#h`m h_/5CJOJQJ^JaJ#h`m h_/6CJOJQJ^JaJ#h`m h_/6CJOJQJ^JaJ#h2ph_/5CJOJQJ^JaJh_/5CJOJQJ^JaJ h2ph_/CJOJQJ^JaJ.jhE CJOJQJU^JaJmHnHu#jhE CJOJQJU^JaJ/jthE h CJOJQJU^JaJ8 : "#YZ !" X !gdE X !gdE !gdCS !gdCS %gd_/ %gd_/HVWX~$CQRSȷȷȷoȷWȷIhCSCJOJQJ^JaJ/jhE hE CJOJQJU^JaJ/jXhE hE CJOJQJU^JaJ/jhE hE CJOJQJU^JaJ/j hE hE CJOJQJU^JaJ h2ph_/CJOJQJ^JaJ#jhE CJOJQJU^JaJ/jhE hE CJOJQJU^JaJhE CJOJQJ^JaJS]^  FJ LNbdfpr|ȰȟyȰȟaȰȟRh_/5CJOJQJ^JaJ/jxhE hE CJOJQJU^JaJ/jhE hE CJOJQJU^JaJhCSCJOJQJ^JaJ h2ph_/CJOJQJ^JaJ.jhE CJOJQJU^JaJmHnHu#jhE CJOJQJU^JaJ/jhE h CJOJQJU^JaJhE CJOJQJ^JaJtvxz|"$$$l$$P%R%%%% !gdE  !dhgdCS !dhgdCS !gdCS %gd_/ %gdCS X !gdE  X !gdE $$$$$ $$$B$D$F$Z$\$^$h$j$Ϸݟݎ}eݟݎMݟ/jhE hE CJOJQJU^JaJ/j`hE hE CJOJQJU^JaJUh_/5CJOJQJ^JaJ h2ph_/CJOJQJ^JaJ.jhE CJOJQJU^JaJmHnHu/jhE hE CJOJQJU^JaJhE CJOJQJ^JaJ#jhE CJOJQJU^JaJ hE hE CJOJQJ^JaJORMTEXT       Postal Address:  FORMTEXT       State:  FORMTEXT      Post Code:  FORMTEXT       Telephone:  FORMTEXT       Fax:  FORMTEXT       Email address: FORMTEXT       Thank you for taking the time to complete this form. This form can be returned to us via email, mail or fax. 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