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Registration Form
2010 LQAS

Note: The information provided will only be used for the purpose of the workshop and will not be disclosed to any party.

 
Name * :  
Gender (circle)* : Male Female  
State* :  
LGA* :  
Health Facility :  
Organization :  
Current Position :  
Telephone number:* :  
E-mail* :  
Education (Highest diploma/degree) :  
Area of expertise (mention only one) :  
Previous Experience in (circle as appropriate) :    
LQAS survey : Yes No
Health Facility Assessment : Yes No
Cluster Survey : Yes No
 
Experience as Master Trainer/Facilitator : Yes No  
Willing to facilitate session : Yes No  
If yes, circle : Classroom Field  
Expectation from the workshop (brief in one or two lines):  
 
     
 
.....
 

Public Health Services and Solutions

2nd Floor, Orji Uzor Kalu House, Off Ahmadu Bello Way, Central Area, Abuja, Nigeria
Phone: 07067275270, 07056777272, 234-09-8733015 | Email: mizansiddiqi@thephss.org, phssnigeria@gmail.com
Web: www.thephss.org/nmcp
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