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EPOS humanitarian survey
Q.1
First Name
Last Name
Q.2
ONE - Does your hospital have a specific humanitarian programme to treat patients?
YES
NO
Q.3
If YES, please specify:
IF NO, THANK YOU FOR YOUR REPLY
Q.4
TWO - Are you personally involved in humanitarian organisations?
YES
NO
Q.5
If YES, please specify:
Q.6
THREE - Are you personally involved in missions to specific countries?
YES
NO
If YES:
Q.7
i. Where and when have you been in 2012 - 2013? 1. Name of institution 2. City 3. Country 4. Dates of the visit 5. Duration of the stay
Q.8
ii.Where and when will you go in 2014? 1. Name of institution 2. City 3. Country 4. Dates of the visit 5. Duration of the stay
Q.9
iii. Do you go 1. Alone 2. With a surgeon colleague 3. With operating room nurse 4. With anesthesiologist 5. With other
Q.10
iv.Clinical activity in 2012 - 2013
YES
NO
Q.11
v.If YES 1. Approximate number of outpatient clinics 2. Approximate number of surgical procedures
Q.12
vi. Teaching activity in 2012 - 2013
YES
NO
Q.13
If YES 1. Number of teaching 2. Main topics
Q.14
vii.Research activity in 2012 - 2013
YES
NO
Q.15
IF YES, PLEASE SPECIFY
Q.16
FOUR - Is one of your colleagues (in your institution) involved in such work?
YES
NO
IF YES:
Q.17
i. Where and when have they been in 2012 - 2013? 1. Name of institution 2. City 3. Country 4. Dates of the visit 5. Duration of the stay
Q.18
ii.Where and when will they go in 2014? 1. Name of institution 2. City 3. Country 4. Dates of the visit 5. Duration of the stay
Q.19
Clinical activity in 2012 - 2013
YES
NO
Q.20
If YES: 1. Approximate number of out patients clinic 2. Approximate number of surgical procedure
Q.21
iv. Teaching activity in 2012 - 2013
YES
NO
Q.22
If YES 1. Number of teaching hours 2. Main topics
Q.23
v.Research activity in 2012 - 2013
YES
NO
Q.24
If YES Please specify:
Q.25
FIVE - Other comments
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