Please answer the following questions:
Please ensure that all the below questions have been answered honestly and accurately before submitting.
Should the below be in order, a SOSPOSA appraisal agent will contact you to set up an appointment shortly.
The appraisal agent will supply you with a document of requirements for the appraisal meeting.
Please ensure that you have all in order for the meeting, otherwise this might result in you not getting verified, and not being able to enjoy the benefits this appraisal offers SOSPOSA Members!
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Question 1 of 41
1. Question
Q1. Please provide us with your title:
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Question 2 of 41
2. Question
Q2. Please provide your initials
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Question 3 of 41
3. Question
Q3. Please provide your full name
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Question 4 of 41
4. Question
Q4. Please provide us with your surname
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Question 5 of 41
5. Question
Q5. Please provide us with your ID number
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Question 6 of 41
6. Question
Q6. Please provide us with a copy of your ID document/card
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Question 7 of 41
7. Question
Q7. Please provide us with you physical address
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Question 8 of 41
8. Question
Q8. In which province do you live in within South Africa?
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Question 9 of 41
9. Question
Q9. What is the postal code of your area?
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Question 10 of 41
10. Question
Q10. Please provide us with your contact number and alternative contact number
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Question 11 of 41
11. Question
Q11. Please provide us with an email address
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Question 12 of 41
12. Question
Q12. Please mark the appropriate option
CorrectIncorrect -
Question 13 of 41
13. Question
Q13. Please provide SOSPOSA Membership Number
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Question 14 of 41
14. Question
Q14. Please provide HPCSA Registration Number
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Question 15 of 41
15. Question
Q15. Please upload a copy of the document displaying your HPCSA registration number
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Question 16 of 41
16. Question
Q16. Please provide your BHF number:
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Question 17 of 41
17. Question
Q17. Please upload the document displaying your BHF number:
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Question 18 of 41
18. Question
Q18. Please provide us with your practice number:
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Question 19 of 41
19. Question
Q19. Please list your medical qualifications with dates, You will upload the supporting documents in the next question:
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Question 20 of 41
20. Question
Q20. Please upload the supporting documents of your medical qualifications
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Question 21 of 41
21. Question
Q21. Please list your formal sedation qualifications with dates
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Question 22 of 41
22. Question
Q22. Please upload the documents with you formal sedation qualifications
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Question 23 of 41
23. Question
Q23. Should you not have formal qualification documents in sedation, please supply us with a 300 – 600 word summary of your experience in sedation, as well as the type of sedation performed, together with your logbook and monitoring cards. (You will supply documents of the cases in the next question)
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Question 24 of 41
24. Question
Q24. Please supply at least 10 consecutive cases documents if you do not have formal qualification documents in sedation (Ex. logbook and monitoring cards)
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Question 25 of 41
25. Question
Q25. For how many years have you been providing PSA?
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Question 26 of 41
26. Question
Please indicate the number of adult and paediatric sedation procedures done in the last year and the technique used:
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Simple or standard sedation technique
Please fill in the blanks:
a. Oral, transmucosal, or rectal sedation only: Adults and Children
b. Intravenous sedation using Midazolam: Adults and Children
c. Inhalation sedation using only Nitrous Oxide (N2O): Adults and Children
Advanced sedation techniques (using anaesthetic drugs or a combination of drugs)
d. Inhalation sedation using other inhalation agents only: Adults and Children
e. Inhalation sedation in conjunction with intravenous sedatives: Adults and Children
f. Oral, transmucosal or, rectal sedation with intravenous sedation: Adults and Children
g. Intravenous sedation using a combination of drugs: Adults and Children
h. Other (Please state) :
CorrectIncorrect -
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Question 27 of 41
27. Question
Q27. The number of general CPD points over the last two years, and where did you obtain them (excluding SOSPOSA Congresses):
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Question 28 of 41
28. Question
Q28. Please provide us with a copy of the documents containing your CPD points
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Question 29 of 41
29. Question
Q29. Please provide us with the number of sedation CPD points over the last two years, and where did you obtain them (excluding SOSPOSA Congresses):
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Question 30 of 41
30. Question
Q30. Please provide us with the date and name of last airway certification (e.g. BLS/APLS/PACLS):
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Question 31 of 41
31. Question
Q31. Please upload a copy of your last airway certification (e.g. BLS/APLS/PACLS):
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Upload your answer to this question.
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Question 32 of 41
32. Question
Q32. Do you keep a logbook of sedation cases? (yes/no)
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Question 33 of 41
33. Question
Q33. If you answered YES to keeping a logbook of patients’ records of adult and/or paediatric cases, please attach it electronically.
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Question 34 of 41
34. Question
Q34. Please upload a copy of your Consent form as supplied by your Practice to your clients/patients:
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Question 35 of 41
35. Question
Q35. Please upload a copy of your Medical questionnaire form as supplied by your Practice to your clients/patients:
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Upload your answer to this question.
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Question 36 of 41
36. Question
Q36. Please upload a copy of your Pre- and post-operative advisory form as supplied by your Practice to your clients/patients:
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Question 37 of 41
37. Question
Q37. Do you have Indemnity Insurance? (yes/no)
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Question 38 of 41
38. Question
Q38. If you have indemnity insurance then please provide us with 1. Insurance company name & 2. Premium Number:
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Question 39 of 41
39. Question
Q39. Please upload a copy of the document that proofs you have indemnity insurance
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Question 40 of 41
40. Question
Q40. Please provide an address of all facilities/rooms/offices where PSA has been administered for the past two (2) years:
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Question 41 of 41
41. Question
Q41. Are you satisfied that the facility/facilities & rooms meet the requirements for safe practice according to the SASA Guidelines? (yes/no). If your answer is NO, please elaborate:
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