Self-nomination Form - Influenza Summit - London

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* 1. Thank you for your interest in participating in the 2nd Influenza Vaccinations Policy Focus Group Meeting taking place in London in December 2016. Please provide your name, country of practice, title, affiliation, email address and phone number

Name:

Country:

Title:

Affiliation:

Email:

Phone:

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* 2. Please copy and paste your latest biography into the box below (up to 400 words)

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* 3. Please describe what you feel your contribution to the Summit will be? (up to 400 words)

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* 4. Do you have a role in the decision making process of vaccination policies in your country? (Please provide further information on your role/work next to each option)

Government - Health Ministry:

Government Vaccinations Committee:

Medical Association - Vaccinations Committee:

Academic Institution - Research:

Health Policy Institution:

Vaccinations Advocacy Groups:

I am simply interested: