Full time one day course,( 07:30-16:30) - Priority will be given to those who provide care for the paediatric surgical patients.-
Email address *
1.Select preferred PPLS course date *
Target group- Doctors /Nurses caring for paediatric surgical patients ( OT/ICU/ETU)
2. Full Name *
As per your ID card/Passport/Birth Certificate
Your answer
3. Surname followed by initials *
e.g; Premaratne E.M.J
Your answer
4. How your name should appear on the certificate *
Please double check the Name.
Your answer
5. First name *
For the name tag
Your answer
6. Mobile number *
Your answer
7. Designation *
If answer is other - Please mention in your comments
8. Specialty / Area of practice *
9. If your answer is "Other" to above question, state the specialty or place of work
Your answer
10. Hospital/ Institution *
e.g , P.G.H Badulla , D.G.H. Gampaha / B.H. Panadura / NHSL / Locum, None
Your answer
11. Date of Birth *
12. University *
e.g- Colombo University
13. If your answer is " Overseas or Other" for above question, state the University
Your answer
14. Post graduate qualification if any
15. SLMC Registration number *
If not registered yet , indicate " No"
Your answer
16. Have you completed any of following life support courses with in last 2 years ? *
17. Meal preference *
18. A r u willing to become an PPLS Instructor *
There will be an Instructor course for selected & limited candidates who have shown interest in teaching
19. Please provide any other relevant Information to Support your application *
e.g. You are involving in teaching CPR ,
Your answer
20. I hereby agree that the above information are true and correct according to my knowledge, and will check my email box and respond accordingly *
A copy of your responses will be emailed to the address you provided.
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google. Report Abuse - Terms of Service