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European Centre for Disease Prevention and Control
Collaborative Network for Travel and Tropical Medicine		 ECDC logo
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MEMBER REGISTRATION FORM

Registration Form To Become A EuroTravNet Network Member

Note: Street addresses and affiliations will be derived from the ISTM membership database.  Non-ISTM members are not eligible for EuroTravNet membership at this time.

NETWORK MEMBER INFORMATION:
Last Name*:

First Name*:
  * Must be the name of the registered ISTM member.
City:

Country:

Email:

Telephone:
   country code

  city code

  phone number
Fax:
   country code

  city code

  phone number
Profession:
Physician
Nurse
Other
Physicians Only - Check all specialty certifications that apply:

  Primary Care Specialty   Yes   No
  Infectious Diseases   Yes   No
  Tropical Medicine   Yes   No
  Occupational Medicine   Yes   No
  Public Health Degree   Yes   No
24-hour contact:  Because of time-zone differences EuroTravNet on rare occasions may need to contact you during non-office hours for urgent follow-up information in clinical event reports.  Please provide a single best telephone number for this purpose.   This information will be kept confidential and known only to the EuroTravNet Secretariat.

Emergency
Contact
Number		  
 country code
 city code
 phone number		  Home
 Mobile
 Pager
 
 
 
 

SECRETARIAT AND INFORMATION MANAGEMENT
Pr. Philippe PAROLA,
Marseille, Project Director
secretariat@eurotravnet.eu

TRAVEL RISKS, PRECAUTIONS AND VACCINATION REQUIREMENTS
Working Group:
Pr. Gerd-Dieter BURCHARD, Hamburg
Pr. Frank von SONNENBURG, Munich
Pr. Francesco CASTELLI, Brescia
and Pr. Patricia SCHLAGENHAUF,
Zurich, Co-ordinator

EPIDEMIC INTELLIGENCE
AND RESPONSE
Dr. Philippe GAUTRET,
Marseille, Co-ordinator
surveillance@eurotravnet.eu