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Your Details:





Address Details:





Postgraduate programme:




Who will pay your UCT fees?

Who will pay your UCT fees?
   
Current Employment:

Please indicate whether Operational Manager, Ward Sister, Educator or other (100 characters max)




(To whom leave forms and progress report will be sent to)



When did you start working in your current position?





What is the main area of your work?















Clinical area where I work, if non of the above

Please indicate whether you are working in a Primary health, Secondary health or Tertiary health institution
Age of the majority of the Patients:





In your ward, how many patients require, on one shift:




Number of patients in an average shift requiring invasive ventilation

Number of patients on an average shift requiring non invasive CPAP

Number of patients in an average shift requiring advanced ventilation (oscillation, nitric oxide, ECMO)
Additional Information:



By providing the information requested you will be agreeing that your personal information (including the personal information contained on this enrolment form and your training activity data) may be used or disclosed by the Child Nursing Practice Development Initiative (CNPDI) for statistical, reporting, regulatory and research purposes. The Child Nursing Practice Development Initiative in collaboration with, and under the auspices of, the University of Cape Town’s data and privacy policy, may disclose your personal information for these purposes to third parties, including:
  • Child Nursing Practice Development Inititiative donors/funders – even if you are enrolled in the programme funded by a donor or not;
  • Government departments and authorised agencies;
  • Researchers involved in monitoring and evaluation of the CNPDI.
Should you have questions or concerns about this, you are welcome to contact the Initiative Director Dr Minette Coetzee (Child Nurse Practice Development Initiative, Faculty of Paediatrics and Child Health, University of Cape Town) at telephone: 021 658 5492 or by email at minette.coetzee@uct.ac.za with any questions about the use of this data or your part in it (there is also an answering service on this line, so feel free to leave your number and she will return your call). The collection of this data has been subject to review and approval by the HREC (Human Research Ethics Committee) of the University of Cape Town. If you have any questions or concerns about the study, please contact the HREC (Human Research Ethics Committee) at (021) 406 6338 or by email to: shuretta.thomas@uct.ac.za

 Thank you so much for taking the time to complete this form.