First Name

Preferred Name (if different to first name)

Date of Birth

Surname

Name, location of medical school and Year of graduation?

Briefly tell us about your post graduate surgical training and qualification.

Which hospital do you work in?

In which country are you located?

Do you have any existing companionships or partnerships with institutions internationally? Do you have any existing companionships or partnerships with institutions internationally? Yes No

Email Address

Are you a General Surgeon practicing in a tertiary hospital that does not currently offer vascular surgery, and interested in participating in Global Vascular Companionship? Are you a General Surgeon practicing in a tertiary hospital that does not currently offer vascular surgery, and interested in participating in Global Vascular Companionship? Yes No

What is/are your preferred languages?

What are the specific goals you wish to achieve from participating in the GVC program? Please provide a detailed response.

If yes, please provide details

What language do your patients speak?

What language are your written medical notes in?

What are the most common vascular surgical conditions in your region? e.g. PVD, diabetic foot infection, venous insufficiency/ulceration

What is the size of the catchment population served by your hospital? What is the size of the catchment population served by your hospital? *Less than 100,000Between 100,000 and 500,000Between 500,000 and 1,000,000More than 1,000,000Unsure

Does your hospital have an emergency department? Does your hospital have an emergency department? Yes No

What international language(s) do your staff speak?

Does your hospital perform surgeries under general anaesthetic? Does your hospital perform surgeries under general anaesthetic? Yes No

Does your hospital conduct surgery out of business hours? Does your hospital conduct surgery out of business hours? Yes No

Does your hospital have an intensive care unit? Does your hospital have an intensive care unit? Yes No

Which of the following surgical specialties do you have? (select all that apply) Which of the following surgical specialties do you have? (select all that apply) General Surgery Colon and Rectal Surgery Cardio and Thoracic Surgery Neurological Surgery Obstetrics and Gynaecology Surgery Opthalmic Surgery Paediatric Surgery Plastic Surgery Urology Vascular Surgery

How many surgeons work at your hospital? How many surgeons work at your hospital? *Less than 5Between 5 and 10Between 10 and 20More than 20

Which of the following vascular surgeries are performed at your hospital? (tick all that apply) Which of the following vascular surgeries are performed at your hospital? (tick all that apply) Arteriovenous fistula creation for renal access Bowel resection and anastomosis Carotid endarterectomy Diabetic/high-risk foot surgery Femoral endarterectomy Femoral thrombectomy Femoral popliteal bypass Lower limb angiogram and angioplasty Major limb amputations Minor limb amputations Open abdominal aortic aneurysm repair Tunnelled cuffed central venous catheter for renal access

In terms of medical imaging, which of the following services does your hospital provide? In terms of medical imaging, which of the following services does your hospital provide? CT MRI Ultrasound Doppler Vascular Ultrasound Digital Subtraction Angiography (specify mobile c-arm or fixed c-arm Coronary Angiography

Do you offer haemodialysis? Do you offer haemodialysis? Yes No

Major Limb Amputations (if yes, please indicate how many)

Do you have high-risk foot service? Do you have high-risk foot service? Yes No

Do you have good access to blood products? Do you have good access to blood products? Yes No

Do you have access to any of the following professionals? (tick all that apply) Do you have access to any of the following professionals? (tick all that apply) Podiatrist Orthotist Dietitian Wound Nurse

Do you currently have links with an international hospital? Do you currently have links with an international hospital? Yes No

If yes, please describe

Do you have your hospital's support in developing your vascular surgery capacity through participation in the Global Vascular Companionship Program? Do you have your hospital's support in developing your vascular surgery capacity through participation in the Global Vascular Companionship Program? Yes No

Can you provide a brief overview of what you are hoping to achieve from the program?

Please provide any further information you would like us to know

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