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.
Contact information
*
First Name
Last 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
*
Format: (000) 000-0000.
Your current position
*
College/University Dean
College/University Professor
College/University Administrator
Other
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
Respiratory Therapy
Radiology Technician
Veterinary
Dentistry
Other
How soon would you like to implement the curriculum?
As soon as possible
Spring 2025
Summer 2025
Fall 2025
Just looking for information at this time.
College/University Name (No Acronyms please)
*
College/University Acronym (UCLA, USC, ....)
Location
*
City
State / 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 Media
B Braun
Press Release
Your Institution
Another Association other than AVA
Presentation
Contacted directly
Other
If you heard of this from a direct communication, another Association or "other" please clarify
AVA Use Only
Please Select
Complete
Contacted
Enrolled
Duplicate
Archive
Industry/Clinical
Declined
I give my permission to B. Braun Medical Inc. to contact me.
*
No
Yes
Submit
Should be Empty: