Paediatric Intensive Care Retrieval Outreach Study Day
Application Form
Date: 6th May 2011
Venue: Heartbeat Suite Southampton General Hospital
Name: ..............................................................................Title:.........................
Job Title Grade...................................................................................................
Speciality.............................................................................................................
Hospital..............................................................................................................
Contact Address.................................................................................................
...........................................................................................................................
...........................................................................................................................
Email address.....................................................................................................
Telephone Number Work....................................................................................
Telephone Number Home....................................................................................
We will be running clinical scenario training during some of the afternoon
sessions.
Please could you indicate if you would be willing to be a participant in the
scenario training?
Yes, I am willing to participate during the scenario training .........................
No, I would prefer to be an observer during the scenario training...................
Please email your completed application form to:
chevon.nunn@suht.swest.nhs.uk
or send it to:
Chevon Nunn
Paediatric Intensive Care
Room CD151
D Level, Centre Block
SGH, Tremona Rd, Southampton. SO16 6YD
If you have any further enquiries regarding this day please email:
Jill Thistlethwaite:
Liz Poingdestre:
Gareth Jones:
jill.thistlethwaite@suht.swest.nhs.uk
elizabeth.poingdestre@suht.swest.nhs.uk
gareth.jones@suht.swest.nhs.uk