Name *

First Name

Last Name

Are you a Hepatitis B S100 Prescriber? Or does your clinic have a Hepatitis B S100 Prescriber? *

I am a Hepatitis B S100 Prescriber

My clinic has a Hepatitis B S100 Prescriber

None of the above

How many patients with chronic hepatitis B (CHB) do you currently have? *

0

1 - 5

6 - 10

More than 10

How confident are you in your ability to identify and screen people at risk of CHB? *

Not confident

Somewhat confident

Very confident

How confident are you in your ability to interpret test results and diagnose CHB? *

Not confident

Somewhat confident

Very confident

How confident are you in your ability to monitor CHB patients and prescribe treatment when required? *

Not confident

Somewhat confident

Very confident

How confident are you in your ability to educate patients regarding prevention, including vaccination for hepatitis B? *

Not confident

Somewhat confident

Very confident

How confident are you to take on new CHB patients from the Culturally and Linguistically Diverse (CALD) Community? *

Not confident

Somewhat confident

Very confident

Did you know that you can refer CHB patients and people at risk of hepatitis B to the Deen Clinic (of HepatitisWA) in Perth? *

Yes

No

Do you have the capacity to take on new patients if HepatitisWA referred CHB patients or people at risk of hepatitis B to you? *

Yes

No

If you answered yes to the previous question, can we include your details in a data base to refer CHB patients or people at risk of hepatitis B to you? *

Yes

No