We use cookies to provide website functionality and collect anonymous visitor data to improve your experience.
Agreed
Leave
Courses
Calendar
Awards
Log In
Return to Work
Book A Place
Dates
06/12/22
Location
On-line
View Map
Cost
Free
REGISTRATION & PRE-COURSE QUESTIONNAIRE Thank you for enrolling on our Anaesthetics/ICM Return to Work Course! Our aim is to improve your confidence in part by allowing you to think about some clinical scenarios and Return To Work issues in a confidential and safe environment. In order for you to get the most out of the session we would be grateful if you complete the questions below. Information will be shared with the faculty, but will otherwise be kept confidential.
Name (which will show up on your certificate of attendance)
required
Contact number
required
Email address
required
Ensure you check your junk/spam folders for booking confirmation.
Grade
Required. Select all that apply
Core Trainee
Specialty Trainee
Registrar
Specialty Doctor/Trust doctor/SAS
Consultant
Specialty
Required. Select all that apply
Anaesthesia
ICM
Dual
other
Dates of Leave to Return
required
Leave and Return Hospital(s):
required
If you feel able to share - reason for time out:
required
On-call areas covering on return if known (e.g. ICM, Obs / 1st call / 2nd call
required
Have you attended any KIT (Keeping in Touch) days?
required
Yes
No
Details:
required
Did you cross-specialty HEENE SuppoRTT morning (trainees only)
required
Yes
No
Do you have any specific concerns, questions or requests for topics covered in the course?
required
Would you be interested in joining a Peer WhatsApp or support group after the course?
Required. Select all that apply
Yes
No
Comments:
required
I agree to my name, email address and booking information being stored and used for the purposes of contacting me about A-line courses. I understand that I can withdraw this consent at any time and that my data will not be passed on to any 3rd party.
Complete Booking
