2024-2025 College and University PIV Curriculum Interest

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.
Primary Contact*

First NameLast Name
Credentials
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)*
example@example.com
Phone Number*
Your current position*

College/University DeanCollege/UniversityProfessorCollege/University AdministratorOther
If selecting "other" please elaborate:
Which program(s) will use this curriculum? (Select all that apply)*

Nursing and/or Nurse PractitionerMedicine and/or Physician AssistantRespiratory TherapyRadiology TechnicianVeterinaryDentistryOther
How soon would you like to implement the curriculum?

As soon as possibleSpring 2025Summer 2025Fall 2025Just looking for information at this time.
College/University Name (No Acronyms please)*
College/University Acronym (UCLA, USC, ....)
Location*

CityState / Province
Postal / Zip Code*
Country
Please indicate your primary reasons for interest in the PIV Curriculum:*
How did you hear about this program?*

AVA Website or Social MediaB BraunPress ReleaseYour InstitutionAnother Association other than AVAPresentationContacted directlyOther
If you heard of this from a direct communication, another Association or "other" please clarify
AVA Use Only
I give my permission to B. Braun Medical Inc. to contact me.*

NoYes
Should be Empty:

College and University Curriculum Information Form