New Centre Registration Form - EBMT Activity Survey

New Centre Registration Form - EBMT Activity Survey
Address of Centre*

Centre Name

Unit

CityPostal / Zip Code

Postal CodeCountry
Team:*
Names of physicians involved in your clinic
Type of centre*

AdultsPaediatricsBoth
Contact Person 1*
Contact Email 1*
example@example.com
Contact Person 2 (optional)
Contact Email 2 (optional)
example@example.com
EBMT CIC

This survey is run by EBMT and is open to members and non-members to fill out. For our internal purposes and analysis, including the benchmarking report, we would like to know if your centre has or has had an EBMT CIC. If you have never been a member, please skip these questions.
EBMT CIC (If currently a member)
EBMT CIC (If historically was a member)
GDPR*

The personal data provided will be processed according to theGeneral Data Protection Regulation (GDPR 2016/679) and stored in an electronicdatabase located in the EEA (European Economic Area) or in countries that areprovided with the same level of protection for privacy. Data Subjects have theright of access, rectification of his/her personal data and to withdrawconsent. If, as a Data Subject, you wish to exercise any of the rights listedabove, please write to data.protection@ebmt.org. For further information pleasego to the Privacy Policy on www.ebmt.org/privacy-policy
HistoricCIC (hidden)
CIC for pre-fill (hidden)
DRST CIC for German centres
Activity Survey ID (hidden)
Should be Empty: