2018 CRM & Simulation Registration form
Surname (De Fernando ) *
Your answer
Name on the tag ( Kamal) *
Your answer
Name how it should appear in the certificate *
Your answer
Mobile number(without initial zero) (eg-778899220) *
Your answer
Your e mail (please send a test mail to cpd.slcp@gmail.com) *
Your answer
NIC or Passport Number *
Your answer
Have you done Paed BASIC course before
Have you done the APLS before *
In which year have done APLS
Have you participated in Pediatric simulation or Crisis Resource Management courses before *
Do you have a reasonable understanding of concepts of Paed simulation *
Do you have a reasonable understanding of concepts of Crisis Resource Management *
Your place of work (Multiple ticks) *
Your Position / Designation *
Your Consultant's or immediate supervisor's name *
Your answer
Currently are you working under a Paediatrician? *
Your Specialty *
PG Trainees - Please tick your stage of training
Your Hospital *
Teaching Hospital
Provincial GH
District General Hospitals
Base Hospital A
Base Hospital B
Province you are working *
Institution of undergraduate medical degree *
Year of your internship *
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