Participant List Course name ATLS® (9th Edition) Date of course Course serial number Name of regional centre (provided when RCS (organising body e.g. hospital/Trust/university) approves your course) Name of course venue (physical location where course held) Course administrator (name, phone and email) Email this form no later than one week after the course to . Please complete the boxes in full, ensuring the relevant critique forms are attached, as failure to provide the information requested will lead to a delay in the issue of certificates. THE NAME SHOWN BELOW WILL BE THE ALONG WITH THE NAME PRINTED ON THE CERTIFICATE NAME OF THE REGIONAL CENTRE Max First Last Post & Specialty Workplace GMC Date of Email address MCQ Pass Items IP 24 name(s) name Grade number score status Check (Mr, (hospital name not Trust – box if Ms, Dr unless NHS locum) (if not (include if P/F/I YES etc) applicable no GMC then DOB number) must be (ddmmyy) given) 1 2 3 4 5 6 7 8 9
Participant List Course name ATLS® (9th Edition) Date of course Name of regional centre (organising body e.g. hospital/Trust/university) Course serial number (provided when RCS approves your course) Name of course venue (physical location where course held) Course administrator (name, phone and email) Email this form no later than one week after the course to . Please complete the boxes in full, ensuring the relevant critique forms are attached, as failure to provide the information requested will lead to a delay in the issue of certificates. THE NAME SHOWN BELOW WILL BE THE NAME PRINTED ON THE CERTIFICATE ALONG WITH THE NAME OF THE REGIONAL CENTRE Max 24 (Mr, Ms, Dr etc) First name(s) Last name Post & Grade Specialty Workplace (hospital name – not Trust unless NHS locum) GMC number (if not applicable then DOB must be given) Date of (include if no GMC number) (ddmmyy) Email address MCQ score Pass status P/F/I Items IP Check box if YES 1 2 3 4 5 6 7 8 9
atls-final-participant-list-form.docx