> Self Notify

AMR Self Notification

If you have recently been diagnosed with mesothelioma, please notify the AMR by completing the online form below.

If you choose to participate in the registry you will receive an information pack containing:

Information sheet
Consent form
Questionnaire

Participation involves completing a questionnaire and taking part in a short telephone interview about your:

Occupational and residential history;
School/education;
Family mesothelioma history (if any).

The information you supply will help to improve understanding about mesothelioma and asbestos exposure. Participation is voluntary and you can withdraw at any time by contacting the AMR. When completing the Questionnaire, don’t worry if you can’t remember something about your history. Any information that you provide is valuable. The purpose of the Questionnaire is to help identify when you have come into contact with asbestos during your life. Once the questionnaire is completed and returned you will be asked to take part in a short telephone interview involving more detailed questions about your potential asbestos exposure.

Fields marked with an * are mandatory.

First name*	First name is required
Last name*	Last name is required
Date of Birth
Select Sex
Address line 1
Address line 2
Suburb
Postcode
Select State/Territory*	State or Territory is required
Email address	Email is required
Contact phone*	Contact number is required
Comments

I have read and accept the privacy policy.

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