IPNA Sister Center Application

IPNA Sister Center Application
Supporting Center
Applicant full name *

First NameLast Name
Applicant email*
example@example.com
Applicant phone number*
Applicant CV*

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Name of Supporting Center*
City*
State
Country*
Support letter from Hospital CEO or Department Leader*

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Past IPNA Fellows
List any past IPNA fellows currently working in your center, and the centre or country in which they trained, Including the periods of training
Emerging Center
Applicant full name *

First NameLast Name
Applicant email*
example@example.com
Applicant phone number*
City
Applicant CV*

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Name of Emerging Center*
City*
State
Country*
Support letter from Hospital CEO or Department Leader*

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The remaining portion of the application should be jointly completed by supporting and emerging centers
Planned language of communication between two centres *
Is this a common spoken language or is it chosen because of shared basic knowledge for communication? *

Check list of currently available resources at emerging and supporting centres*

Rows	EMERGING CENTRE Pediatric	EMERGING CENTREAdult	EMERGING CENTREavailable elsewhere in city/region	SUPPORTING CENTREPediatric	SUPPORTING CENTREAdult	Comments & Clarifications
Intensive Care Unit
Surgery (subspeciality)
Urology (subspeciality)
Cardiology (subspeciality)
Hematology (subspeciality)
Neurology (subspeciality)
Pulmonary (subspeciality)
Percutaneous Kidney Biopsy
Light microscopy
Immunofluorescence
Electron microscopy
Voiding Cystourethrogram
Radionuclide Studies
Urodynamics
Acute hemodialysis
Chronic hemodialysis
Acute Peritoneal Dialysis
Chronic Peritoneal Dialysis
Continuous Kidney Replacement Therapy
Plasmapheresis
Kidney Transplantation

Specific goal(s) to be achieved over 2 years of this partnership *
What steps over what time period have you planned during the 2 years to achieve these goals? Please upload the details following THIS EXAMPLE.

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Has there been any previous collaboration between the two centers? If yes, please elaborate. *
Have you applied before for an IPNA Sister Renal Centers Program or any other similar programs with financial support? If yes, please provide brief details. *
Do you have other sources of funding to help with this partnership and goals? If yes, please provide brief details. *
Financial plan with breakdown of how money will be spent. CLICK HERE for an example of a budget and attach your specific planned budget. *

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Should be Empty:

Supporting Center