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Eurotherm trial participation form

Please write your details clearly below:

Name*
Department*
Hospital*
Address*
City*
PostCode*
Country*
Direct Telephone No.*
Direct Fax No.*
Email*

If you would like to be a collaborator in the EuroTherm Trial please answer the questions below

Number of beds in your (Neurological) Intensive Care Unit (ICU)*
Number of traumatic brain injured patients admitted to your ICU per year (approximately)*
Do you have experience of cooling patients either to normothermia or hypothermia ?*
Yes
No
If yes, which patient groups do you have experience in cooling ?*
Cardiac arrest
Traumatic brain injury
Other
Do you use a cooling device ?*
Yes
No
If yes, please give the name of the device
Do you monitor Intracranial Pressure (ICP)?
Yes
No
Does your unit have a hypothermia protocol ?
Yes
No
Does your unit have a shivering protocol ?
Yes
No
Do you have previous research experience ?
Yes
No
Do you have a research nurse or research support at your site ?
Yes
No

* mandatory fields
Adresse Eurotherm