Additions or Corrections to US Prehospital Blood Map
POCs for the Map are Randi Schaefer (randi.schaefer@schaeferconsulting.net) and Eric Bank (Eric.Bank@hcesd48.org)

The information provided is voluntary and may be used to support the Prehospital Blood Transfusion Initiative Coalition's (PHBTIC) efforts.

PHBTIC Website: https://prehospitaltransfusion.org/
Sign in to Google to save your progress. Learn more
Is this a new addition to the map, correction, or update? *
Type of Agency *
Name of Agency *
City

 *
For Air Medical Transport Agencies, please provide the location of your base. Do not put all supported counties/states.
For Ground Agencies with multiple locations, please provide your Headquarters location. 
State  *
Type of Blood Products Carried (Select ALL that apply) *
Required
Date Program Started *
MM
/
DD
/
YYYY
Type of Agency *
Who provides your blood? *
Name of Blood Provider *
Blood Logistics Model *
Number of Days The Agency Has the Blood Product(s) On-Hand *
Name of Point of Contact *
Point of Contact Email *
Additional Comments *
The PHBTIC receives requests for blood-carrying agencies to participate in academic research. Please indicate your preference for your agency contact information to be shared for the purposes of better understanding prehospital blood use. This is NOT for market research or device sales. *
Submit
Clear form
Never submit passwords through Google Forms.
This form was created inside of schaeferconsulting.net.

Does this form look suspicious? Report

Google Forms