Pharmabridge

Pharmabridge – Questionnaire Form

This form can be filled out online and submitted directly to the Coordinator by typing in the answers to the questions and clicking the submit button once finished. When completing the form, please do not use capital letters only.

First Name *

Last Name *

Street

Zip/Postalcode

City

Country *

Phone

Fax

Email *

Professional status*

Other* :

Institution where you are based

Field of pharmacy practice (very brief description of work and focus of interest):

1. Participation in areas described in the project:

1.1 Supply of books, CDs etc

Describe needs:

Describe potential offers:

1.2 Fellowships, faculty exchange etc

I/institution etc am/is interested in establishing a twinning relationship (for e.g. exchange of information, visits, support etc.) with an institution or an individual as follows:

Describe needs:

Describe possible offers/cooperation:

1.3. Twinning arrangements

I/institution etc am/is interested in establishing a twinning relationship (for e.g. exchange of information, visits, support etc.) with an institution or an individual as follows: national pharmacists association
faculty of pharmacy
hospital pharmacy
drug information centre
individual pharmacist
Other (please describe):

2. Information on other ongoing schemes falling within the scope of Pharmabridge

e.g. Pharmaid as operated by the Commonwealth Pharmaceutical Association, or a fellowship scheme for pharmacists from developing countries

2.1 Describe such schemes:

2.2 Indicate whether you agree that these schemes could be referred to as additional information/link under the Pharmabridge project

3. General Suggestions/Comments

Description:

4. Include Name and Email address

In the event that a list of addresses of people participating in Pharmabridge would be established for inclusion on the Pharmabridge website, would you agree that your name and contact information would be included in such a list? Yes No