Please enable JavaScript in your browser to complete this form.Please enable JavaScript in your browser to complete this form.PERSONAL INFORMATIONName *FirstLastGenderMaleFemaleDate of BirthNationalityGhanaInternationalEmail * (copy) Title INSTITUTIONAL Phone *Single Line TextPROFESSIONAL DETAILSCurrent Job Title *CadreTheatre In-ChargePerioperative NurseOR Manager / CoordinatorOther (Specify)Years of Experience in Operating Theatre (Operating theatre experience only)0–2 years3–5 years6–10 years10+ yearsINSTITUTIONAL INFORMATIONName of Facility *Type of Facility (Select primary facility)Teaching HospitalRegional HospitalDistrict HospitalPrivate HospitalMission/CHAG FacilityOther (Specify)Region *Department *INSTITUTIONAL APPLICATION (OPTIONAL)I am applying on behalf of an institution / nominating multiple staff.Request bulk invoice YesNoNumber of NomineesSUPPORT & SPONSORSHIPFunding SourceSelf-fundedInstitution-sponsoredIf Institution-Sponsored *Request official invoiceYesSupervisor Recommendation *FirstMiddleLastINSTITUTIONAL APPROVALSupervisor Recommendation (copy) *FirstLastUpload signed approval letter Drag & Drop Files, Choose Files to Upload AVAILABILITY & COMMITMENTAvailability (All must be confirmed)1-week online pre-course2-week onsite training at UGMC90-day implementation phaseCommitment to Capstone Project (Required for Certification)YesNoPRIOR TRAINING (OPTIONAL)Have you attended any OR management or leadership training before?YesNoIf yes, SpecifyDECLARATIONHave you attended any OR management or leadership training before? (copy)I confirm that the information provided is accurateI commit to full participation, including the implementation phaseI consent to be contacted by SCN-GhanaSubmit
