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<head><title>Global Foodborne Infections Network Survey on Campylobacter diagnosis 2014 (EN)</title>
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Please provide the following details for the relevant reference laboratory:
</span>Country name:</label></td><td style="width:80%;padding-top:3px;" valign="top"><input id="text_552134330_6419149557" name="text_552134330_6419149557" class="open" type="text" size="50" value="Ethiopia" /></td></tr><tr><td style="width:20%;"><label for="text_552134330_6419149558">Contact Point name:</label></td><td style="width:80%;padding-top:3px;" valign="top"><input id="text_552134330_6419149558" name="text_552134330_6419149558" class="open" type="text" size="50" value="Firehiwot Abera, Ethiopian Public Health Institute" /></td></tr><tr><td style="width:20%;"><label for="text_552134330_6419149559">Alternate Contact Point (if any) name:</label></td><td style="width:80%;padding-top:3px;" valign="top"><input id="text_552134330_6419149559" name="text_552134330_6419149559" class="open" type="text" size="50" value="Bisrat Habtemariam" /></td></tr><tr><td style="width:20%;"><label for="text_552134330_6419149560">Date form completed:</label></td><td style="width:80%;padding-top:3px;" valign="top"><input id="text_552134330_6419149560" name="text_552134330_6419149560" class="open" type="text" size="50" value="June 20/2014" /></td></tr><tr><td style="width:20%;"><label for="text_552134330_6419149561">Institution</label></td><td style="width:80%;padding-top:3px;" valign="top"><input id="text_552134330_6419149561" name="text_552134330_6419149561" class="open" type="text" size="50" value="Ethiopian Public Health Institute" /></td></tr><tr><td style="width:20%;"><label for="text_552134330_6419149562">Laboratory name</label></td><td style="width:80%;padding-top:3px;" valign="top"><input id="text_552134330_6419149562" name="text_552134330_6419149562" class="open" type="text" size="50" value="Food Microbiology section" /></td></tr><tr><td style="width:20%;"><label for="text_552134330_6419149563">Name in local language</label></td><td style="width:80%;padding-top:3px;" valign="top"><input id="text_552134330_6419149563" name="text_552134330_6419149563" class="open" type="text" size="50" value="Yemegeb Microbiology" /></td></tr><tr><td style="width:20%;"><label for="text_552134330_6419149564">Address</label></td><td style="width:80%;padding-top:3px;" valign="top"><input id="text_552134330_6419149564" name="text_552134330_6419149564" class="open" type="text" size="50" value="Patriot street , woreda 8, Kebele 10" /></td></tr><tr><td style="width:20%;"><label for="text_552134330_6419149565">Status (Public/Private/Other)</label></td><td style="width:80%;padding-top:3px;" valign="top"><input id="text_552134330_6419149565" name="text_552134330_6419149565" class="open" type="text" size="50" value="Public" /></td></tr><tr><td style="width:20%;"><label for="text_552134330_6419149566">Name of the person completed the questionnaire</label></td><td style="width:80%;padding-top:3px;" valign="top"><input id="text_552134330_6419149566" name="text_552134330_6419149566" class="open" type="text" size="50" value="Firehiwot Abera Derra" /></td></tr><tr><td style="width:20%;"><label for="text_552134330_6419149567">Position</label></td><td style="width:80%;padding-top:3px;" valign="top"><input id="text_552134330_6419149567" name="text_552134330_6419149567" class="open" type="text" size="50" value="Researcher" /></td></tr><tr><td style="width:20%;"><label for="text_552134330_6419149568">Email</label></td><td style="width:80%;padding-top:3px;" valign="top"><input id="text_552134330_6419149568" name="text_552134330_6419149568" class="open" type="text" size="50" value="firehiwot_a@yahoo.com; wudefre2013@gmail.com" /></td></tr><tr><td style="width:20%;"><label for="text_552134330_6419149569">Phone</label></td><td style="width:80%;padding-top:3px;" valign="top"><input id="text_552134330_6419149569" name="text_552134330_6419149569" class="open" type="text" size="50" value="+2519484550" /></td></tr></table></div></div></div></div></div>
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