The information collected will be held by the VAST Team and will not be shared. Required fields are marked with a * Course Info Course Date* Please input a YYYY-mm-dd date (2020-10-13) Course Type* VAST Facilitator Instructor Course Location* Australia - Perth Canada - Halifax Canada - Prince George Canada - Whitehorse Ethopia - Addis Abba Fiji - Suva India - Hyderabad Rwanda - Butare Rwanda - Kibagabaga Rwanda - Kigali Rwanda - Kubatare Rwanda - Nyagatare Rwanda - Rwamagana Tanzania - Dar Es Salaam Course Role Participant Trainee facilitator Facilitator Simulation coordinator Observer Personal Info Last Name* First Name* Clinical Role* Anesthesia technician/assistant Anesthesia trainee GP anesthetist Medical officer Medical student Midwifery Non clinical Non physician anesthetist Nursing Obstetrics Physician anesthesiologist Surgery Workplace* Level 1:Small hospital/health centre Level 2:District/provincial hospital Level 3:Referral hospital Prior Simulation Experience* Yes No Have you attended a simulation course before? Email* Home Country* Afghanistan Albania Algeria American Samoa Andorra Angola Anguilla Antarctica Antigua And Barbuda Argentina Armenia Aruba Australia Austria Azerbaijan Bahamas Bahrain Bangladesh Barbados Belarus Belgium Belize Benin Bermuda Bhutan Bolivia Bosnia And Herzegovina Botswana Bouvet Island Brazil British Indian Ocean Territory Brunei Darussalam Bulgaria Burkina Faso Burundi Cambodia Cameroon Canada Cape Verde Cayman Islands Central African Republic Chad Chile China Christmas Island Cocos (Keeling) Islands Colombia Comoros Democratic People's Republic of Korea Democratic Republic Of The Congo Cook Islands Costa Rica Cote D'ivoire Croatia Cuba Cyprus Czech Republic Denmark Djibouti Dominica Dominican Republic East Timor Ecuador Egypt El Salvador Equatorial Guinea Eritrea Estonia Ethiopia Falkland Islands Faroe Islands Fiji Finland France French Guiana French Polynesia French Southern Territories Gabon Gambia Georgia Germany Ghana Gibraltar Greece Greenland Grenada Guadeloupe Guam Guatemala Guinea Guinea-bissau Guyana Haiti Heard Island And Mcdonald Islands Holy See (Vatican City State) Honduras Hong Kong Hungary Iceland India Indonesia Iran Iraq Ireland Israel Italy Jamaica Japan Jordan Kazakstan Kenya Kiribati Kosovo Kuwait Kyrgyzstan Laos Latvia Lebanon Lesotho Liberia Libyan Arab Jamahiriya Liechtenstein Lithuania Luxembourg Macau Macedonia Madagascar Malawi Malaysia Maldives Mali Malta Marshall Islands Martinique Mauritania Mauritius Mayotte Mexico Federated States Of Micronesia Republic Of Moldova Monaco Mongolia Montserrat Montenegro Morocco Mozambique Myanmar Namibia Nauru Nepal Netherlands Netherlands Antilles New Caledonia New Zealand Nicaragua Niger Nigeria Niue Norfolk Island Northern Mariana Islands Norway Oman Pakistan Palau Palestinian Territory Panama Papua New Guinea Paraguay Peru Philippines Pitcairn Poland Portugal Puerto Rico Qatar Romania Russian Federation Rwanda Saint Helena Saint Kitts And Nevis Saint Lucia Saint Pierre And Miquelon Saint Vincent And The Grenadines Samoa San Marino Sao Tome And Principe Saudi Arabia Senegal Serbia Seychelles Sierra Leone Singapore Slovakia Slovenia Solomon Islands Somalia South Africa South Georgia And The South Sandwich Islands The Republic of South Korea Spain Sri Lanka Sudan Suriname Svalbard And Jan Mayen Swaziland Sweden Switzerland Syrian Arab Republic Taiwan Tajikistan Tanzania Thailand Togo Tokelau Tonga Trinidad And Tobago Tunisia Turkey Turkmenistan Turks And Caicos Islands Tuvalu Uganda Ukraine United Arab Emirates United Kingdom United States of America United States Minor Outlying Islands Uruguay Uzbekistan Vanuatu Venezuela Vietnam British Virgin Islands US Virgin Islands Wallis And Futuna Western Sahara Yemen Zambia Zimbabwe Gender* Male Female Prefer not to answer Mailing List Yes No Would you like to join the VAST Mailing List to receive correspondence and updates from VAST in the future? "Human check"* 7 × 3 = ? Please answer the math problem above