| NATIONAL Study

Critical Care Unit Information Form
NATIONAL (iNdian AnalgosedaTION And deLirium)

State*  
City *  
Name of the Hospital*  
Total number of ICU Bed*  
Total number of Hospital Beds*  

HOSPITAL DEMOGRAPHICS

Type of hospital *  
Public  
Private  

INVESTIGATOR INFORMATION

(Up to two investigator can be Registered per ICU)

Details of Principle Investigator

First*  
Middle
Last*  
Email*    
Cell no*  

Details of Co Investigator 1

First*  
Middle
Last*  
Email*    
Cell No*  

Details of Co Investigator 2

First
Middle
Last
Email  
Cell No

Address of Hospital

Address 1*  
Address 2 *  
Address 3
City *  
State*  
Pincode *  

Contact details

Email*    
Alternate Email  
Contact Number*  
Alternate Contact Number