College and University Curriculum Information Form
Please complete this form if you would like information on the PIV Curriculum. These courses are for Colleges and Universities, not for individual students or licensed clinicians. This is only available in English at this time.
E-mail address (by submitting your email address, you give the Association for Vascular Access and/or B. Braun Medical Inc., permission to contact you)
Your current position
If selecting "other" please elaborate:
Which program(s) will use this curriculum? (Select all that apply)
Nursing and/or Nurse Practitioner
Medicine and/or Physician Assistant
How soon would you like to implement the curriculum?
As soon as possible
Just looking for information at this time.
College/University Name (No Acronyms please)
College/University Acronym (UCLA, USC, ....)
State / Province
Postal / Zip Code
Please indicate your primary reasons for interest in the PIV Curriculum:
How did you hear about this program?
AVA Website or Social Media
Another Association other than AVA
If you heard of this from a direct communication, another Association or "other" please clarify
I give my permission to B. Braun Medical Inc. and/or The Association for Vascular Access to contact me (if you click no, we will not follow up but you will receive an automated response from jotform).
Should be Empty: