Referral Form

Welcome to your first step in MicroResearch International Online Curriculum. Please fill in the areas below.

For any technical issues with the online curriculum, or problems loging onto the system please contact Jaimie Corbin:

I Need Help!

For all Nova Scotia based inquiries please contact Heather Rushton at:
MicroResearchNS@dal.ca

For all Africa based inquiries please contact Mary Appleton at: MicroResearch@dal.ca

First name*

Last name*

Email address

Date of Birth (mm-dd-yyyy)

Demographic Information

Have you, or are you planning to attend one of our MicroReseach workshops?

Yes

No I have not attended at workshop.

If yes, where does the workshop take place? If no, what location is of interest to you?

What is the year of your attend workshop?

Gender?
This information is for research purposes only.

Male

Female

Please indicate the learning group to which you belong.

Africa / Asia Participant (general interest, workshop attendee, healthcare professional)

Nova Scotia Participant (general interest, workshop attendee, healthcare professional)

Africa / Asia MicroResearch Coach (teachers and facilitators)

Nova Scotia MicroResearch Coach (teachers and facilitators)

ALL Africa / Asia & Nova Scotia MicroResearch Coach

None Of The Above

Notice