| NATIONAL Study

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

If the hospital has more than one ICU, each ICU should register separately

State*
City *
Centre Number*
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)

Name of Principle Investigator

First*
Middle *
Last*
Email*
Cell no*

Name of Co Investigator

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*
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