KnowledgeShare Request – Online Form

Title

First Name(required)

Surname(required)

Email(required)

Work Address

Telephone

Purpose. eg education or research(required)

Age Groups(required) Select Neonates Children & Adolescents Adults Elderly

Condition/Risk Factors. eg gestational diabetes(required)

Settings. eg GP surgery or hospital ward(required)

Other

May we make your contact details and interests visible to all members of KnowledgeShare in order to promote knowledge sharing? Yes with everyone Yes with members of my organisation No only with library staff

Date

I understand and agree to my data being held in accordance with the Data Protection Act (1998) on the South and West Information Management System and KnowledgeShare.(required)