Apllicant Form ADVANCED OPERATING ROOM (OR) MANAGEMENT PROGRAMME PERSONAL INFORMATION Name * Name First Name First Name Last Name Last Name Date of Birth * Gender Male Female Email * Phone * Nationality GhanaInternational PROFESSIONAL DETAILS Current Job Title * Cadre * Theatre In-Charge Perioperative Nurse OR Manager / Coordinator Other (Specify) Years of Experience in Operating Theatre * 0–2 years 3–5 years 6–10 years 10+ years INSTITUTIONAL INFORMATION Name of Facility * Type of Facility (Select primary facility) * Teaching Hospital Regional Hospital District Hospital Private Hospital Mission/CHAG Facility Other (Specify) Region * Department * INSTITUTIONAL APPLICATION (OPTIONAL) Request bulk invoice Yes No I am applying on behalf of an institution / nominating multiple staff Yes No Number of Nominees SUPPORT & SPONSORSHIP Funding Source Yes No If Institution-Sponsored If Institution-Sponsored Sponsoring Institution Sponsoring Institution Contact Person (Finance/Admin) Contact Person (Finance/Admin) Contact Email/Phone Contact Email/Phone Request official invoice Yes No Supervisor Recommendation Supervisor Recommendation Supervisor Name Supervisor Name Position Position Contact Contact INSTITUTIONAL APPROVAL Head of Facility Head of Facility Approving Authority Name Approving Authority Name Position Position Upload Approval Letter (pdf only) Drop a file here or click to upload Choose File Maximum file size: 8MB AVAILABILITY & COMMITMENT Availability (All must be confirmed) 1-week online pre-course 2-week onsite training at UGMC 90-day implementation phase Commitment to Capstone Project (Required for Certification) Yes No PRIOR TRAINING (OPTIONAL) Have you attended any OR management or leadership training before? Yes No If yes, Specify DECLARATION Have you attended any OR management or leadership training before? * I confirm that the information provided is accurate I commit to full participation, including the implementation phase I consent to be contacted by SCN-Ghana Submit If you are human, leave this field blank.
