PIV Curriculum Information Form (Hospitals, Clinicians and Individuals)
Please complete this form if you would like to be informed regarding the rollout of the upcoming PIV Curriculum/Courses. We have developed curriculum for practicing clinicians and healthcare facilities. Currently, this is only available in English.
Primary Contact
*
First Name
Last Name
E-mail address (by submitting your email address, you give the Association for Vascular Access and/or B. Braun Medical Inc., to contact you)
*
example@example.com
Phone Number
*
Format: (000) 000-0000.
Your current position
*
Hospital Administrator/supervisor
Practicing clinician
Student
Other
If selecting "other" please elaborate:
Which license do you hold?
*
Nursing and/or Nurse Practitioner
Medicine and/or Physician Assistant
Respiratory Therapy
Radiology Technician
Veterinary
Dentist
Other
How soon would you like to implement the curriculum?
As soon as possible
1st quarter 2025
2nd quarter 2025
3rd quarter 2025
4th quarter 2025
Just looking for information at this time.
Name of Hospital or facility (No Acronyms please)
*
If not in a facility, type N/A
Location
*
City
State / Province
Postal /Zip Code
*
Country
Please indicate your primary reasons for interest in the PIV Curriculum:
*
Request for
Hospital/Institution
Individual/Self
How did you hear about this program?
*
AVA Website or Social Media
B Braun
Press Release
Your Institution
Another Association other than AVA
Other
If you heard of this from another Association or "other" please clarify
Are you interested in hearing about our Ultrasound Guided PIV Insertion Education?
Yes
No
I give my permission to SJC Vascular Access, and B. Braun Medical Inc. to contact me.
*
No
Yes
Submit
Should be Empty: