Registration Form All fields of asterisk mark (*) are mandatory. *Full Name *Gender MaleFemale Date Of Birth *Qualification *Name of Hospital/Clinic/Org *Designation Postal Address Pin Code *Mobile No. TelePhone. *Email Alternate Email Infrastructure *Type Of Setup eg;Private clinic, public hospital, medical college Hospital Sector PrivatePublic *Number Of Beds *ICU Setup YesNo If Others Specification Do You Have Diagnostic Centre? Specification *Do you have an access to Institutional/Independent Ethics Committee? YesNo If Yes, Name of IEC? How often does the IEC meet? Research Interest Enclose a copy of your current CV emphasizing experience in Research (Upload Word or PDF format file, not more than 5mb.) What are the reasons for which you wish to participate in research studies? Areas of Research Interest in Respiratory Medicine *How many academic research projects have you started in the last 1 year 012345101520 *Have you ever conducted any clinical trials YesNo *Have you ever presented any original research work at any conference YesNo On an average, how much time are you willing to dedicate to research work in a day How many students/assistants do you have to conduct research Last four (1) publications Last four (2) publications Last four (3) publications Last four (4) publications Patient Pool Details Do you maintain a database of patients If yes, please indicate the database is Asthma COPD IPF Bronchiectasis Pulmonary TB Any Other Diseases Which of the following diagnostics you have access to ? Laboratory Investigations (Blood) YesNo Comment X - Ray YesNo Comment HRCT YesNo Comment MRI YesNo Comment IOS YesNo Comment DLCO YesNo Comment Body Plethysmography Test Name of Body Plethysmography YesNo Comment Spirometer Name of Spirometer YesNo Comment PEFR YesNo Comment 6 Minute Walk Test YesNo Comment Treadmill Exercise Testing YesNo Comment Sputum Induction & Processing YesNo Comment Sputum AFB YesNo Comment Skin Prick Test YesNo Comment Bronchial Challenge Test YesNo Comment BAL Samplings YesNo Comment Lung Tissue Samplings YesNo Comment Others Comment
