ࡱ> *,)[@ dbjbj44 C@ViVidT<|!n4444444|~~~?] $"R<%!!44444!!446!>>>4v44|>4|>>4 l@hL!0|!%%%T44>44444!!!! ( EMBED CorelDRAW.Graphic.9  QUESTIONNAIRE FORM REGARDING THE STRUCTURE AND ORGANISATION OF HOSPITALS, WHICH TRAIN AO FELLOWS 1) Name of hospital: Address: Tel.: Fax: 2) Name of department where the fellow is trained: 3) Head of department: 4) Who is in charge of the fellows: Email address: 5) No. of beds in the department: 6) No. of senior residents/registrars: 7) Facilities for outpatients: - outpatient department? yes / no - special consultation hours? Yes / no - specialities, e. g.: 8) Polytrauma patients (various major fractures or combination of fractures and cerebro-spinal, thoracic or abdominal injuries) per year (approx.): a) integrated intensive care unit: yes / no b) intensive care unit together with other specialities yes / no c) assisted respiration cases per year (approx.): d) neurosurgery in the hospital: yes / no e) cardio thoracic surgery in hospital: yes / no 9) Approx. total number of operations (trauma and orthop.) per year: a) estimated % of trauma: b) estimated % of elective orthopaedics: c) osteotomies of the hip: yes / no (this is often a wish of doctors coming from developing countries) 10) Specialities (state the approx. % in relation to all operations) - children: yes (........ %) or no - hand: yes (........ %) or no - spine: yes (........ %) or no - maxillofacial: yes (........ %) or no - pelvis: yes (........ %) or no - others: - are these specialities a part of the department ( or independent ( or in another hospital - head(s) of speciality department(s): 11) Special neighbouring hospitals, which could be visited by the fellow yes / no a) name(s) of hospital(s): b) head(s) of department(s): 12) Current scientific activities of the hospital (clinical/basic research): 13) Other activities of the hospital in which an interested fellow could take part (e.g. staff-meetings with other specialities etc.): 14) Can the fellow assist scrubbed at the operations? yes / no If yes, how often? 15) Will the fellow be called at emergencies at night / weekends? yes / no 16) Lodging and board a) does he/she have a room in the hospital area? yes / no b) if not, where will he/she stay? Describe facility (apartment/room): Distance to hospital: c) approx. rent of the room per week: d) is there a call-system between his/her room and the hospital? yes / no Availability in the apartment/room - bed linen and towels: YES ( NO ( - cooking facilities: YES ( NO ( - personal phone: YES ( NO ( - television: YES ( NO ( - internet access: YES ( NO ( - Hospital canteen available? YES ( NO ( - Approx. cost per meal? 17) Do you prefer fellows from a particular country, region or continent? yes / no - if yes, from which one (will be treated confidentially): 18) Can you accommodate more than one fellow at the same time? yes / no (maximum ......... fellows at the same time) 19) Please describe in brief outlines the route between the nearest international airport and the hospital: 20) Travel of the AO fellow Please describe briefly the route between the nearest international airport and the hospital with time indication: 21) Administration Responsible person in the hospital for - Booking the accommodation: - Welcoming+orientating the fellow: - Handing over the room key: Please submit name of bank and bank account no for the transfer of the stipend. 22) Welcome package of the host hospital for the AO fellow Do you offer a welcome package to the AO fellow YES ( NO ( If yes does it contain: - information sheet with name, phone no, time of availability of the person taking care of the AO fellow during his/her stay: YES ( NO ( - information brochure/sheet on the hospital YES ( NO ( - rules of the hospital YES ( NO ( - site plan of the hospital YES ( NO ( - working clothes/shoes YES ( NO ( - vouchers for the hospital canteen YES ( NO ( - others: 23) Additional remarks / suggestions: Place, Date: Signature: Please send the completed form to the following address: President of AO International Clavadelerstrasse CH-7270 Davos Platz Switzerland / Fax number: +41 81 414 22 83 THANK YOU VERY MUCH INDEED! 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