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INTUBE study - Call for center form
Please fill in this form completely and press the "send" button at the end of this page (one application for each institution).
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Email
*
Your email
INternational observational study To Understand the impact and BEst practices of airway management of critically ill patients
Institution name
*
Your answer
Type of hospital
University/Academic hospital
Non-academic hospital
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Department
*
Your answer
Address
*
Your answer
Post code
*
Your answer
City
*
Your answer
Country
*
Your answer
Number of ICUs of your institution
Your answer
Total number of ICU beds
Your answer
How many in-hospital endotracheal intubations of critically ill patients are performed in your institution in a week?
1 - 5
6 - 10
11 - 15
> 15
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Principal investigator
Title
Dr.
Prof.
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Last name
*
Your answer
First name
*
Your answer
Date of birth
MM
/
DD
/
YYYY
Office phone
Your answer
Mobile phone
Your answer
E-mail
*
Your answer
Second contact person
Title
Dr.
Prof.
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Last name
Your answer
First name
Your answer
E-mail
Your answer
I give my permission to publish my center name on the INTUBE study website (
www.intubestudy.com
)
*
YES
NO
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