Resuscitative TEE Collaborative Registry

JavaScript isn't enabled in your browser, so this file can't be opened. Enable and reload.

Intake Form & Confirmation of Participation

For centers that will be participating with more than one clinical unit / department (i.e. ED and ICU), please fill one form for each participating clinical unit (with the unit's Site-PI), unless it will be the same Site-PI for both units. In that case please fill out one form and specify in the comment section at the end.

Hospital Name (As it should be listed) *

City *

Country *

University or Medical School Affiliation (If applicable, otherwise enter N/A) *

Full Name of Site-Principal Investigator (Site-PI) *

Site-PI Title and Division, Department or Clinical Unit *

Email *

Phone Number (include country & area code if not USA) *

Name of Research Contact Person (i.e. Research Coordinator / Assistant, Fellow, etc. if applicable, otherwise enter N/A) *

Email of Research Contact Person (i.e. Research Coordinator / Assistant, Fellow, etc. if applicable, otherwise enter N/A) *

Comments

Submit

Clear form

Never submit passwords through Google Forms.

This content is neither created nor endorsed by Google. Report Abuse - Terms of Service - Privacy Policy

Forms