Authorised by Head of Department * Signed: (only to be completed for Locums / Independent/Overseas Perfusionists Print: Date of Procedure Hospital / Centre OFFICE USE Type of Procedure POINTS AWARDED Name(s) of Perfusionist(s) Name of Surgeon Name of Anaesthetist Number Authorised by Head of Department * Signed: (only to be completed for Locums / Independent/Overseas Perfusionists Print: Date of Procedure Hospital / Centre OFFICE USE Type of Procedure POINTS AWARDED Name(s) of Perfusionist(s) Name of Surgeon Name of Anaesthetist Number Authorised by Head of Department * Signed: (only to be completed for Locums / Independent/Overseas Perfusionists Date of Procedure Hospital / Centre OFFICE USE Type of Procedure POINTS AWARDED Name(s) of Perfusionist(s) Name of Surgeon Name of Anaesthetist Number Authorised by Head of Department * Signed: (only to be completed for Locums / Independent/Overseas Perfusionists
Authorised by Head of Department * (only to be completed for Locums / Independent/Overseas Perfusionists Signed: Print: Date of Procedure Hospital / Centre OFFICE USE Type of Procedure POINTS AWARDED Name(s) of Perfusionist(s) Name of Surgeon Name of Anaesthetist Number Authorised by Head of Department * (only to be completed for Locums / Independent/Overseas Perfusionists Signed: Print: Date of Procedure Hospital / Centre OFFICE USE Type of Procedure POINTS AWARDED Name(s) of Perfusionist(s) Name of Surgeon Name of Anaesthetist Number Authorised by Head of Department * (only to be completed for Locums / Independent/Overseas Perfusionists Signed: Date of Procedure Hospital / Centre OFFICE USE Type of Procedure POINTS AWARDED Name(s) of Perfusionist(s) Name of Surgeon Name of Anaesthetist Number Authorised by Head of Department * (only to be completed for Locums / Independent/Overseas Perfusionists Signed:
Clinical%20Activity%20Report%20form.docx