ECLS 360

Pre-Program Assessment

Thank you for expressing interest in partnering with ECLS 360 to support your ECLS program. We are excited about the opportunity to collaborate and help enhance your program's effectiveness and impact.

Please complete the following questionnaire. Once submitted, a member of our team will reach out to discuss the next steps.

Basic Information

Tell us about yourself and your institution

Program Specifics

Details about your ECLS program

What stage is your ECLS Program in? *
What population of patients does your program place on ECLS? * (Select all that apply)
How many patients does your program support each year? *
What type of ECLS does your center perform? * (Check all that apply)

Staffing & Personnel

Information about your ECLS team

Who performs ECLS cannulations at your center? * (Check all that apply)
Who are the staff responsible for managing ECLS at the bedside in your program? * (Check all that apply)

Areas of Interest & Improvement

Help us understand your goals

What areas within your ECLS Program do you feel need improvement? (Check all that apply)
What areas are you most interested in learning more about that ECLS 360 has to offer? (Check all that apply)

Additional Details

A few more questions to complete your assessment

Does your Program currently complete Interfacility transports? *
What ECLS system(s) is your program currently utilizing? * (Check all that apply)
How did you hear about us? *

Thank you for taking the time to complete this survey. One of our team members will be in touch with you shortly.