Pediatric Patient Blood Management Masterclass
Applicant Survey
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Name *
Email Address *
Gender *
Current Institution and Location *
Professional Title(s) *

How many years have you been in clinical practice after residency training?

 *

Hospital size:  

 *

Professional Specialty:

 *
Anesthesiology (please specify subspecialty), Surgery (please specify subspecialty),  Transfusion Medicine, Hematology, Other (please specify)

Does your institution have a Patient Blood Management (PBM) Program?

 *
Are you currently involved in patient blood management (PBM) initiatives or bleeding management at your institution?
 *

How many years have you been involved in patient blood management (PBM) initiatives at your institution?

 *

Describe your current role in PBM initiatives or bleeding management.

 *

Example:  I am on the PBM committee and I’m helping to develop viscoelastic testing treatment algorithms OR I have been tasked with building a PBM program. 

If you are involved in PBM initiatives or bleeding management at your institution, list up to 5 topics/projects and your involvement: *
Are Viscoelastic POC testing methods used at your institution?  If yes, in which areas? And which device(s) does your hospital (and you) use for Viscoelastic Testing? (Quantra, TEG 6S, TEG 5000, ROTEM Delta, ROTEM Sigma, ClotPro)
 *

Briefly list obstacles to implementing or further developing patient blood management initiatives or bleeding management algorithms in your institution. 

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(1-2 paragraphs)

Which area(s) of perioperative bleeding management are you most interested in? 

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(Choose all that apply)
Required

Which aspects of bleeding management would you like to learn more about? 

 *
(Choose all that apply)
Required

Do you have a track record of leading process change in your institution (e.g. successful QI project, Division leader, leadership award or role, etc.)? 

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(1-2 paragraph description of accomplishments and/or goals)

How would attending this course help you achieve career goals at your institution? 

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(1-2 paragraphs)

Can you attend in-person and participate in all activities during the 1 day program, May 4, 2023, in Boston, MA?

 *
How did you hear about this Masterclass? *
Required
If you were recommended by a colleague, please list their name(s):
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