July 13, 2006
Please submit completed form to:Merveille.desouza@siu-General InformationPlease note that this application must be sent to SIU a minimum of 12 weeks prior to the event.2857559690Name of live surgery event: Click here to enter text.00Name of live surgery event: Click here to enter text.28575124460Event date (dd/mm/yyyy): Click here to enter a date.00Event date (dd/mm/yyyy): Click here to enter a date.26035138526Event Location: Click here to enter text. STREET ADDRESS Click here to enter text./ Click here to enter text. / Click here to enter text. / Click here to enter text. CITY STATE COUNTRY POSTAL CODE00Event Location: Click here to enter text. STREET ADDRESS Click here to enter text./ Click here to enter text. / Click here to enter text. / Click here to enter text. CITY STATE COUNTRY POSTAL CODE2857565405Local course director: Click here to enter text. Click here to enter text. FIRST NAME LAST NAME Click here to enter text. Click here to enter text. TELEPHONE NUMBER E-MAIL ADDRESS 00Local course director: Click here to enter text. Click here to enter text. FIRST NAME LAST NAME Click here to enter text. Click here to enter text. TELEPHONE NUMBER E-MAIL ADDRESS 28575107950Name of physician requesting SIU endorsement: Click here to enter text.00Name of physician requesting SIU endorsement: Click here to enter text.2857566579E-mail address and website URL for event: Click here to enter text.00E-mail address and website URL for event: Click here to enter text.Is this an application for a live-streaming event? ? Yes ? NoWhich level of endorsement are you requesting? ? Level 1 ? Level 2 ? Level 3Educational Goals and Guidelines -1778073025This event will offer Continuing Medical Education (CME) credits: ? Yes ? No 00This event will offer Continuing Medical Education (CME) credits: ? Yes ? No -19050149860If yes, name the CME-granting body: Click here to enter text.00If yes, name the CME-granting body: Click here to enter text.-95250144780List all members of the planning committee:NameMedical SpecialtyAffiliationCity and CountryE-Mail AddressClick here to enter text.Click here to enter text.Click here to enter text.Click here to enter text.Click here to enter text.Click here to enter text.Click here to enter text.Click here to enter text.Click here to enter text.Click here to enter text.Click here to enter text.Click here to enter text.Click here to enter text.Click here to enter text.Click here to enter text.Click here to enter text.Click here to enter text.Click here to enter text.Click here to enter text.Click here to enter text.Click here to enter text.Click here to enter text.Click here to enter text.Click here to enter text.Click here to enter text.Click here to enter text.Click here to enter text.Click here to enter text.Click here to enter text.Click here to enter text.00List all members of the planning committee:NameMedical SpecialtyAffiliationCity and CountryE-Mail AddressClick here to enter text.Click here to enter text.Click here to enter text.Click here to enter text.Click here to enter text.Click here to enter text.Click here to enter text.Click here to enter text.Click here to enter text.Click here to enter text.Click here to enter text.Click here to enter text.Click here to enter text.Click here to enter text.Click here to enter text.Click here to enter text.Click here to enter text.Click here to enter text.Click here to enter text.Click here to enter text.Click here to enter text.Click here to enter text.Click here to enter text.Click here to enter text.Click here to enter text.Click here to enter text.Click here to enter text.Click here to enter text.Click here to enter text.Click here to enter text. -26581397642 List all operating surgeons: NameMedical SpecialtyAffiliationClick here to enter text.Click here to enter text.Click here to enter text.Click here to enter text.Click here to enter text.Click here to enter text.Click here to enter text.Click here to enter text.Click here to enter text.Click here to enter text.Click here to enter text.Click here to enter text.Click here to enter text.Click here to enter text.Click here to enter text.Click here to enter text.Click here to enter text.Click here to enter text.Click here to enter text.Click here to enter text.Click here to enter text.Click here to enter text.Click here to enter text.Click here to enter text.Click here to enter text.Click here to enter text.Click here to enter text.Click here to enter text.Click here to enter text.Click here to enter text.Click here to enter text.Click here to enter text.Click here to enter text.Click here to enter text.Click here to enter text.Click here to enter text.Click here to enter text.Click here to enter text.Click here to enter text.00 List all operating surgeons: NameMedical SpecialtyAffiliationClick here to enter text.Click here to enter text.Click here to enter text.Click here to enter text.Click here to enter text.Click here to enter text.Click here to enter text.Click here to enter text.Click here to enter text.Click here to enter text.Click here to enter text.Click here to enter text.Click here to enter text.Click here to enter text.Click here to enter text.Click here to enter text.Click here to enter text.Click here to enter text.Click here to enter text.Click here to enter text.Click here to enter text.Click here to enter text.Click here to enter text.Click here to enter text.Click here to enter text.Click here to enter text.Click here to enter text.Click here to enter text.Click here to enter text.Click here to enter text.Click here to enter text.Click here to enter text.Click here to enter text.Click here to enter text.Click here to enter text.Click here to enter text.Click here to enter text.Click here to enter text.Click here to enter text.-106326201517List all planned procedures: Click here to enter text.00List all planned procedures: Click here to enter text.-53163105129Identify educational goals for the overall event: Click here to enter text.00Identify educational goals for the overall event: Click here to enter text.-97657105366Identify educational goals for each procedure: Click here to enter text.00Identify educational goals for each procedure: Click here to enter text.On-site organization, staff and facilitiesI confirm that I have read the CODEX for SIU-endorsed live surgery events and agree to adhere to any guidelines and recommendations outlined in this document, including:Presentation of the case history and reason for surgical procedure will be stated to participants prior to the start of each surgeryAll operating surgeons will be sufficiently skilled and will have received an official invitation letter from the hospital to perform the above-mentioned proceduresAll operating surgeons will be asked to provide documentation regarding potential health risks (e.g. MRSA or Hepatitis B and C)An adequate informed consent process will be implementedThe course director will be responsible for patient care prior to, during and before the procedureAll costs associated with the event will be the responsibility of the course director and his/her organizationI hereby agree to uphold the guidelines listed above and in the SIU Live Surgery CODEX and adhere to the currently-established ethical standards in the country in which the event is being held. _________________________________________________________________________________________SignatureDate ................
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