| Please complete all mandatory fields and click on
the submit button to upload the form. |
| First Name |
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| Last Name |
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| Grade |
Fellow
Yes |
| Fellow Type |
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| Hospital Name |
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| Hospital Address |
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| Trust |
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| Telephone (inc area code) |
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| Email |
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| Mobile |
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| Training Number* |
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| Deanery |
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| Age |
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| Gender |
Male
Female |
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Year Of Graduation (medical school)*
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Year in which you started your speciality training (SpR or ST3)*
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Exit exams: passed*
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What is your speciality aim*
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Years/months of colorectal training (as registrar)*
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Handedness*
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Have you attended a course in laparoscopic colorectal surgery?*
Yes
No |
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If yes, what type of course
animal (porcine)
cadaveric
immersion course (human)
other simulation model
masterclass
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Do you regularly use laparoscopic simulators (box trainers,
virtual reality) at your institution?*
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Do you play video games?*
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Which of the following laparoscopic procedures have you done
as a primary surgeon?
Lap cholecystectomy
Lap appendicectomy
Lap fundoplication
Lap colectomies (all types)
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Which of the following open procedures have you done as a primary
surgeon?
Right hemicolectomy
Sigmoid resection/ High anterior resection
Low anterior resection
Hartman
Abdomino-perineal excision
Total colectomy/ Proctocolectomy
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| Once your details have been verified you will receive
an email with your password to access your account. If you are
having any problems completing or submitting the form contact
the Lapco Coordination Office: 01752 439844 |
