1. 1. First name:*
2. 2. Last name:*
3. 3. Email:*
   (this will be your username)
4. 4. Choose password:*
5. Re-type password:*
6. 5. Occupation:
7. 6. My intended use of this model is:

   To assist me in the clinical investigation of patients with possible occupational asthma that might be due to a to novel respiratory sensitiser To assist me in investigating cases of possible asthma that are not work related but might have been caused by sensitisation to a low molecular weight chemical To assist me in toxicological assessments of novel compounds to which people might be exposed To investigate the possible asthma hazard of chemicals to which I personally might be exposed
8. Other:
9. 7. I am a physician:

   Yes No
10. 8. Type of physican

    Respiratory physican Occupational physician Allergist/ immunologist
11. Other:
12. 9. In an average year i would expect to see the following
    number of cases of occupational asthma casued by a novel
    chemical agent

    No cases 1-4 cases 5-9 cases 10 or more cases
13. 10. If you are a toxicologist or have responsibility for workplace
    risk management please indicate the number of low molecular weight
    chemicals for which you require information on
    possible respiratory sensitising potential per year

    None 1 - 5 6 - 20 > 20

11. Type the characters in the image below
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* compulsory field. An individual password that permits you access to use this programme will be sent via e-mail to this address