PERUKI Site Membership Registration Form

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** MAY 2019 - WE HAVE MOVED TO A FULLY ELECTRONIC REGISTRATION PROCESS - ALL SITES ARE REQUIRED TO RE-REGISTER TO ASSIST WITH THIS **

The EMAIL ADDRESS required is the email address of the SITE REPRESENTATIVE

Do you have the facilities and ability to deliver PEM research at your site? If you would like your department to be one of our member sites you can apply using this form.

This form is to be used when applying for annual PERUKI site membership. It should be completed by the site representative, who may sign on behalf of the institution.

In order to ensure ongoing membership, the site must
• abide by the code of conduct laid out in the PERUKI operational policy
• participate in studies felt by the Research Steering Committee to require data from all sites

Please note,
After you submit this form, a member of the PERUKI Executive Committee will arrange to contact you to discuss membership and what each party can expect from this relationship.

Email *

Full Name of Site Representative - will sit on Research Steering Committee (should be same person who owns email address entered above) *

Site (preferred name for all future publications) *

Health Trust (if different from above)

Department *

Site - Street Address *

Site - City *

Site - Postcode *

Site - Country *

England

Ireland

Northern Ireland

Scotland

Wales

Other:

Annual Paediatric Census (under 16 years of age)

The terms which best describe our site and department are:

Standalone Children's Hospital

District General Hospital

Emergency Department

Paediatric Assessment Unit

Paediatric Major Trauma Centre

Combined Paediatric and Adult MTC

Paediatric Trauma Unit (Adult MTC)

Paediatric Trauma Unit (Adult TU)

Standalone Paediatric Emergency Department

Mixed Emergency Department with separate area for Paediatrics

Mixed Emergency Department with no separate area for Paediatrics

Tertiary Paediatric Hospital

Anything else you need to tell us?

Statement: On behalf of the site, I agree to abide by the code of conduct as described in the document “Operational Policy of Paediatric Emergency Research in the United Kingdom & Ireland (PERUKI)”, available from www.peruki.org. On behalf of the site, I agree to contribute data to those studies which are felt by the Research Steering Committee to require data from all sites. *

Yes

Signed *

Date (DD/MM/YY) *

Send me a copy of my responses.

Submit

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