CERTIFICATION Thursday, 4th October, 14h-17h Last Name* First Name* Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzech RepublicCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Swaziland)EthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaRéunionSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Winners ID / Academy ID* Please enter your Winners ID or Academy IDPhone*Email* If you have already an OSP account, please use the same e-mail.Date of Birth* Gender Male Female Dominant hand side Right Left Affiliation/Institute* ACADEMIC INFORMATIONCurrent Academic Level* Student Resident Specialist in Ob&Gyn Specialist in other discipline Other When you chose "Specialist in other discipline/Other" please specify: EXPOSURE TO ATYPIC PSYCHOMOTOR SKILLSEXPOSURE TO ATYPIC PSYCHOMOTOR SKILLS Video games How many hours per week?* EXPOSURE TO ATYPIC PSYCHOMOTOR SKILLS Musical instrument How many hours per week?* EXPERIENCE IN HYSTEROSCOPY IN THE ORESGE classification is used for description of levels. Please fill in all levels.EXPERIENCE IN LAPAROSCOPY IN THE OR No experience in hysteroscopy Indicate the experience in first (basic) level procedures*These include: Diagnostic Hysteroscopy, Simple procedures (excluding the use of laser or electro-surgery), Target biopies, Removal of IUCD, Minor intrauterine adhesions 0 <30 30-50 >50 Indicate the experience in second (intermadiate) level procedures*These include: Polyp resection, Resection of type 0 myoma, Endometrial ablation, Treatment of uterine septum, Tubal cannulation 0 <30 30-50 >50 Indicate the experience in third (advanced) level procedures*These include: Resection of type 1 and 2 myoma, Major Asherman's syndrome 0 <30 30-50 >50 EXPOSURE WITH HYSTEROSCOPIC HANDS-ON LAB TRAININGAnimal model* No exposure 1-2 sessions Regular exposure (more than 2 sessions a year) Trainer box* No exposure 1-2 sessions Regular exposure (more than 2 sessions a year) Virtual reality* No exposure 1-2 sessions Regular exposure (more than 2 sessions a year) EXPERIENCE IN LAPAROSCOPY IN THE ORESGE Classification is used for descriptions of levels. Please fill in all levels.EXPERIENCE IN LAPAROSCOPY IN THE OR No experience in laparoscopy Indicate the experience in first (basic) level procedures*Diagnostic laparoscopy, Tubal sterilisation, Cyst aspiration, Biopsies 0 <30 30-50 >50 Indicate the experience in second (intermediate) level procedures*Salpingotomy, Salpingectomy, Salpingo-oophorectomy, Cystectomy, Moderate adhesiolysis, Minimal/Mild endometriosis 0 <30 30-50 >50 Indicate the experience in third (advanced) level procedures*Hysterectomy, Myomectomy, Urinary incontinence, Extensive adhesiolysis, Severe endometriosis, Bowel or Bladder lesions reparation 0 <30 30-50 >50 Indicate the experience in fourth level procedures*Pelvic floor disorders, Oncology (Lymphadenectomy, Radical hysterectomy, Axiloscopy), Recto-vaginal endometriosis 0 <30 30-50 >50 EXPOSURE WITH LAPAROSCOPIC HANDS-ON LAB TRAININGAnimal model* No exposure 1-2 sessions Regular exposure (more than 2 sessions a year) Trainer box* No exposure 1-2 sessions Regular exposure (more than 2 sessions a year) Virtual reality* No exposure 1-2 sessions Regular exposure (more than 2 sessions a year) GESEA Certification Level 1 or Level 2Specify for which level you would like to register.Certification*SelectGESEA Level 1 CertificationGESEA Level 2 CertificationTotal 0,00 € Payment type* Credit Card Bank Transfer Credit CardCard Details Cardholder Name Payment details European Academy of Gynaecological Surgery IBAN: BE 03 3300 7314 1084 BIC: BBRUBEBB Reference: Your full nameConsent* I have read and agree with the terms of sale and the privacy policy of the European Academy of Gynaecological Surgery
