Midwest Chapter of SCCM Jeopardy application
*
1.
Institution
(Required.)
*
2.
Participants’s Sub-Speciality
(Required.)
Pediatric Critical Care
Adult Critical Care
Other (please specify)
3.
First Participant’s name?
4.
First Participant’s Year in Training
PGY-1
PGY-2
PGY-3
PGY-4
PGY-5
PGY-6
PGY-7
Other (please specify)
5.
Second participant’s name? (On your team)
6.
Second participant’s year of training
PGY-1
PGY-2
PGY-3
PGY-4
PGY-5
PGY-6
PGY-7
Other (please specify)
7.
Are you a SCCM Member?
Yes
No
8.
Are you Midwest Chapter member?
Yes
No
9.
How did you hear about this event?
10.
At what email address would you like to be contacted?