Operation Abraham, Join Us

Operation Abraham: Recruiting Questionnaire

Thank you for your interest in "Operation Abraham". To be included in our Surgeons and Mohalim database we kindly ask you to fill in the fields below. The information provided by you is kept confidential and will only be used for assignment to future delegations of the project as part of Jerusalem AIDS Project response to scaling up male circumcision for HIV prevention and related research.

Personal Information

Prof. / Dr. / Mr.

First name:

Last name:

Email Address:

Alternate Email Address:

Your Mailing Address:

City:

State:

Country:

Phone Number: (+)

Mobile Number: (+)

Fax Number: (+)

Home Phone: (+)

Primary Nationality:

Additional Nationality:

Information on Education and Qualifications
List the academic programs you have attended and degrees obtained

University name	Degree	Subject	Year Graduated

List the medical licenses and board exam certificates you currently hold

Medical Licenses\ Board Exams	Country	Field	Year Obtained

Information on Experience with Male Circumcision

I have experience with Adult male circumcision

Neonatal

Both

Please describe the experience you have in male circumcision. Report on years of experience, methods you are experienced with (e.g. Sleev, Dorsal Slit, Forceps Guided, Mogan Clamp, Plasty bell)

Motivation

1) Why do you want to participate in Operation Abraham?

2) What additional skills can you offer?

3) Are you expected to be paid or ready to volunteer?

Am expecting a salary/payment for my services

Am happy to volunteer my time, expect all (travel, accommodation etc costs) to be covered by JAIPl

Am happy to volunteer my time and will also take care of my travel and living costs when on mission

Other (please explain)

Experience as a trainer

How are you capable of educating doctors on male circumcision? (The position requires good communication skills to demonstrate and educate doctors on male circumcision). Please elaborate on your experience in training others in male circumcision.

Availability

Operation Abraham Delegations last usually two weeks each. Please indicate dates in which you could be available during 2008 and 2009. Mark two weeks' periods with repeated selections possible.

From (dd/mm/yy):		To (dd/mm/yy):
From (dd/mm/yy):		To (dd/mm/yy):
From (dd/mm/yy):		To (dd/mm/yy):
From (dd/mm/yy):		To (dd/mm/yy):

Comments: