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Serono Symposia International Foundation invites you to provide input into our planning process for future educational programs.
Thank you in advance for completing this form!
What is your primary profession? (Please choose the one area that fits best)
-Please select your profession-
Biologist
Embryologists
LPN/LVN
Nurse
Nurse Anesthetist
Nurse Practitioner
Nutritionist/Dietitian
Pharmacist
Physical Therapist
Physician
Physician Assistant
Psychologist
Registered Nurse
Rehab Specialist
Social Worker
Technician
Student
Trainee
Other Medical/Clinical
Non-Clinical
Other
Profession
Other
In which country do you practice?
-Select Country-
Algeria
American Samoa
Andorra
Angola
Anguilla
Antarctica
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaidjan
Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belarus
Belgium
Benin
Bermuda
Bhutan
Bolivia
Bosnia And Herzegowina
Botswana
Bouvet Island
Brazil
British Indian Ocean Territory
Brunei Darussalam
Bulgaria
Burkina Faso
Burundi
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Croatia (Hrvatska)
Cuba
Cyprus
Czech Republic
Denmark
Djibouti
Dominica
Dominican Republic
East Timor
Ecuador
Educational
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
Former Chechoslovakia
France
French Guyana
Gabon
Gambia
Georgia
Germany
Ghana
Gibraltar
Great Britain
Greece
Greenland
Grenada
Guadeloupe (French)
Guam (USA)
Guatemala
Guinea
Guinea Bissau
Guyana
Haiti
Heard and McDonald Islands
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
International
Iran
Iraq
Ireland
Islamic State of Afghanistan
Israel
Italy
Ivory Coast
Jamaica
Japan
Jordan
Kazakhstan
Kenya
Kingdom of Cambodia
Kiribati
Kuwait
Kyrgyz Republic (Kyrgyzstan)
Kyrgyzstan
Laos
Latvia
Latvia
Lebanon
Lesotho
Liberia
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Mamarrocco
Marshall Islands
Martinique (French)
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldavia
Moldova, Republic Of
Monaco
Mongolia
Montserrat
Mozambique
Myanmar
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia (French)
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Northern Mariana Islands
North Korea
Norway
Oman
Pakistan
Palau
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Island
Poland
Polynesia (French)
Portugal
Puerto Rico
Qatar
Reunion (French)
Romania
Russian Federation
Rwanda
S. Georgia and S. Sandwich Islands
Saint Helena
Saint Kitts and Nevis Anguilla
Saint Lucia
Saint Pierre and Miquelon
Saint Tome (Sao Tome) and Principe
Saint Vincent And Grenadines
Samoa
San Marino
Saudi Arabia
Senegal
Seychelles
Sierra Leone
Singapore
Slovakia (Slovak Republic)
Slovenia
Solomon Islands
Somalia
South Africa
South Korea
Spain
Sri Lanka
Sudan
Suriname
Svalbard and Jan Mayen Islands
Swaziland
Sweden
Switzerland
Syria
Tadjikistan
Taiwan
Tanzania
Thailand
The Democratic Republic of the Congo
Togo
Tokelau
Tonga
Trinidad and Tobago
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
Uruguay
USA
Uzbekistan
Vanuatu
Vatican City State
Venezuela
Venezuela
Vietnam
Virgin Islands (British)
Virgin Islands (USA)
Wallis and Futuna Islands
Western Sahara
Yemen
Yugoslavia
Zaire
Zambia
Zimbabwe
Country
Please rate each of the following topics based on the relevance to your educational needs (please rate using the scale 4 = most relevant, 1 = least relevant)
1
2
3
4
Management of psoriasis in different skin areas
1
2
3
4
Non cutaneous manifestations of psoriasis
1
2
3
4
Role of biologicals in therapeutic protocols of psoriasis
1
2
3
4
Cost/benefit relationship in the therapy of psoriasis
1
2
3
4
Psycho-educational support for psoriatic patients
1
2
3
4
Other
Are there laws in your country regulating Industry sponsorship to attend international congresses?
Yes
No
Which type of educational activity do you consider most beneficial for your Continuing Professional Development?
Interactive workshops/courses (30-60 attendees)
International symposia (200-300 attendees)
Medical Societies International Congresses / Large International Congresses
Are there enough educational activities offered in your country?
Yes
Some, but I also need to go abroad to fulfill my educational requirements
Some, but I also need to attend non specialty related courses to fulfill my educational requirements
No
What topics would you like to see addressed in on-line educational courses?
Optional: If you would like to receive information on Serono Symposia International Foundation activities please type your contact details.
Lastname
Firstname
Degree
Institution
Department
Street
-Select Country-
Algeria
American Samoa
Andorra
Angola
Anguilla
Antarctica
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaidjan
Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belarus
Belgium
Benin
Bermuda
Bhutan
Bolivia
Bosnia And Herzegowina
Botswana
Bouvet Island
Brazil
British Indian Ocean Territory
Brunei Darussalam
Bulgaria
Burkina Faso
Burundi
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Croatia (Hrvatska)
Cuba
Cyprus
Czech Republic
Denmark
Djibouti
Dominica
Dominican Republic
East Timor
Ecuador
Educational
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
Former Chechoslovakia
France
French Guyana
Gabon
Gambia
Georgia
Germany
Ghana
Gibraltar
Great Britain
Greece
Greenland
Grenada
Guadeloupe (French)
Guam (USA)
Guatemala
Guinea
Guinea Bissau
Guyana
Haiti
Heard and McDonald Islands
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
International
Iran
Iraq
Ireland
Islamic State of Afghanistan
Israel
Italy
Ivory Coast
Jamaica
Japan
Jordan
Kazakhstan
Kenya
Kingdom of Cambodia
Kiribati
Kuwait
Kyrgyz Republic (Kyrgyzstan)
Kyrgyzstan
Laos
Latvia
Latvia
Lebanon
Lesotho
Liberia
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Mamarrocco
Marshall Islands
Martinique (French)
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldavia
Moldova, Republic Of
Monaco
Mongolia
Montserrat
Mozambique
Myanmar
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia (French)
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Northern Mariana Islands
North Korea
Norway
Oman
Pakistan
Palau
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Island
Poland
Polynesia (French)
Portugal
Puerto Rico
Qatar
Reunion (French)
Romania
Russian Federation
Rwanda
S. Georgia and S. Sandwich Islands
Saint Helena
Saint Kitts and Nevis Anguilla
Saint Lucia
Saint Pierre and Miquelon
Saint Tome (Sao Tome) and Principe
Saint Vincent And Grenadines
Samoa
San Marino
Saudi Arabia
Senegal
Seychelles
Sierra Leone
Singapore
Slovakia (Slovak Republic)
Slovenia
Solomon Islands
Somalia
South Africa
South Korea
Spain
Sri Lanka
Sudan
Suriname
Svalbard and Jan Mayen Islands
Swaziland
Sweden
Switzerland
Syria
Tadjikistan
Taiwan
Tanzania
Thailand
The Democratic Republic of the Congo
Togo
Tokelau
Tonga
Trinidad and Tobago
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
Uruguay
USA
Uzbekistan
Vanuatu
Vatican City State
Venezuela
Venezuela
Vietnam
Virgin Islands (British)
Virgin Islands (USA)
Wallis and Futuna Islands
Western Sahara
Yemen
Yugoslavia
Zaire
Zambia
Zimbabwe
Country
City
Zip
Email Address
Phone Number
Fax Number
I authorize the processing of my Personal Data in accordance with the Italian Legislative Decree n. 196/2003.
Yes
No
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