WiSSP withdrawal form - Central Queensland

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Closes 30 Mar 2023

Withdrawal form

1. What is your first name?
2. What is your surname?
3. What is your date of birth?
DOB (Required)

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4. Where do you work? Please select the workplace location where you usually drop your swabs
5. I would like to withdraw from the WiSSP program.
(Required)
6. Why would you like to withdraw?
7. What would you like us to do with the results we have already collected from you?
8. What is your email address?
If you enter your email address then you will automatically receive an acknowledgement email when you submit your response.