In what country is your organisation based? * - Select - Afghanistan Albania Algeria American Samoa Andaman and Nicobar Islands Andorra Angola Anguilla Antarctica Antigua and Barbuda Argentina Armenia Aruba Ascension Island Australia Austria Azerbaijan Azores Bahamas Bahrain Balearic islands Bali Bangladesh Barbados Belarus Belgium Belize Benin Bermuda Bhutan Bolivia Borneo Bosnia and Herzegovina Botswana Brazil British Virgin Islands Brunei Darussalam Bulgaria Burkina Faso Burma Burundi Cabrera Cambodia Cameroon Canada Canary Islands Cape Verde Cayman Islands Central African Republic Chad Channel Islands Chile China Christmas Island Cocos (Keeling) Islands Colombia Comoros Cook Islands Corsica Costa Rica Côte d’Ivoire Croatia Cuba Cyprus Czech Republic Democratic Republic of the Congo Denmark Djibouti Dominica Dominican Republic East Timor Easter Island Ecuador Egypt El Salvador Equatorial Guinea Eritrea Estonia Ethiopia Falkland Islands Faroe Islands Fiji Finland Formentera France French Guiana French Polynesia Gabon Galapagos Islands Gambia Georgia Germany Ghana Gibraltar Greece Greenland Grenada Guadeloupe Guam Guatemala Guinea Guyana Haiti Hawaii Honduras Hong Kong Hungary Ibiza Iceland India Indonesia Iran Iraq Ireland Isle of Man Israel Italy Jamaica Japan Jordan Kazakhstan Kenya Kiribati Korea, North Korea, South Kosovo Kuwait Kyrgyzstan Laos Latvia Lebanon Lesotho Liberia Libya Liechtenstein Lithuania Luxembourg Macau SAR Macedonia Madagascar Madeira Islands Majorca Malawi Malaysia Maldives Mali Malta Margarita Island Marshall Islands Martinique Mauritania Mauritius Mayotte Menorca Mexico Micronesia Moldova Monaco Mongolia Montenegro Montserrat Morocco Mozambique Myanmar (Burma) Namibia Nauru Nepal Netherlands Netherlands Antilles New Caledonia New Zealand Nicaragua Niger Nigeria Niue Norfolk Island Northern Mariana Islands Norway Oman Pakistan Palau Palestine Panama Papua New Guinea Paraguay Peru Philippines Pitcairn Islands Poland Portugal Puerto Rico Qatar Republic of Korea (S. Korea) Reunion Romania Russian Federation Rwanda Saint Helena Saint Kitts and Nevis Saint Lucia Saint Martin/Sint Maarten Saint Pierre and Miquelon aint Vincent and the Grenadines Samoa San Marino Sao Tome & Principe Saudi Arabia" "Senegal Serbia Seychelles Sierra Leone Singapore Slovakia Slovenia Solomon Islands Somalia South Africa South Georgia and the South Sandwich Islands Spain Sri Lanka Sudan Suriname Swaziland Sweden Switzerland Syria Tahiti Taiwan Tajikistan Tanzania Thailand Tibet Timor-Leste Togo Tokelau Tonga Trinidad and Tobago Tunisia Turkey Turkmenistan Turks and Caicos Islands Tuvalu Uganda Ukraine United Arab Emirates United Kingdom United States of America Uruguay Uzbekistan Vanuatu Venezuela Vietnam Virgin Islands (British and USA) Wake Island and the US Pacific Islands Wallis and Futuna Islands Western Sahara Yemen Zambia Zanzibar Zimbabwe
IN WHICH TOWN OR CITY ARE YOU BASED? *
What is the name of your organisation/body/university *
Organisation’s website url
Facebook name
Twitter name
Which category best describes your organisation? * - Select - Animal health organisation Charity Environment & Plant Food safety Food and farming Government (local) Government (national) Hospital Human Animal & Food production Patient/People Advocate Pharmacy Primary care Private Healthcare Professional body Public health organisation Student association University Veterinary and animal care Other
IF other, please specify *
How did you find out about registering your organisation to participate in World Antibiotic Awareness Week activities - Select - Africa CDC Colleague Professional organisation's email/newsletter Social media University or school Other
IF other please specify *
What is your role in the organisation? (or on which senior colleague’s behalf are you completing the registration) - Select - Chief Exec/Chair/President Comms lead of a professional organisation Director Comms lead - Other Chief Pharmacist/Head of medicines management Non-Exec director Manager Senior manager Facilities director/manager Operations director/manager Events director/manager Internal communications director/manager Trustee Other
IF other please specify *
Do you know if one or more senior leaders /executives (e.g exec/non-exec directors, chief pharmacists, heads of medicines management, director of nursing, medical director) in your organisation chosen their personal Antibiotic Guardian pledge * - Select - Yes at least 1 Yes 1-5 senior leaders No but will be working on this for WAAW No I am not sure
If yes, to above, please state the job title(s) of the execs/senior leaders that have chosen their individual Antibiotic Guardian pledge *
I have completed the registration on behalf of a senior colleague * - Select - Yes No
If yes, to above, please state the job title(s) of the execs/senior leaders that you have registered on behalf of *
Your Email Address *
IF DIFFERENT PLEASE PROVIDE THE EMAIL ADDRESS OF THE MAIN LEAD FOR AFRICA WAAW/ANTIBIOTIC AWARENESS ACTIVITIES IN YOUR ORGANISATION
Please use this space to share details of other activities that you have planned and are not listed in table 1. Or to provide additional comments/feedback
IF YOUR ORGANISATION WILL CARRY OUT A LOCAL AWARENESS CAMPAIGN AND YOU/OTHER MEMBER OF STAFF CAN REGULARLY WEAR THE ANTIBIOTIC GUARDIAN LANYARD OR BADGE, PLEASE PROVIDE THE EMAIL ADDRESS TO SEND THESE TO.
