Walk Strong Foundation - Site Application

Walk Strong Foundation - Site Application

Online application form for the Walk Strong Foundation Site Application. Please complete all sections, including contact details, orthopedic information, administration and logistics, and signature/date.
Contact Information
Hospital Name
Street Address

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
City
State/Province
Country
Postal Code
Phone
Please enter a valid phone number.Format: (000) 000-0000.
Hospital Website
Shipping Address
Shipping City
Shipping State/Province
Shipping Country
Shipping Postal Code
Program Liaison - Name and Email Address
The Program Liaison is the main contact between the Walk Strong Foundation and the local Total Joint Program. He/she is responsible for management of inventory, supplies, communication and reporting patient outcomes. This person should be willing to engage in long-term commitment of the program.Please provide the name and email address of the individual who will be serving as your Program Liaison:
Orthopedic Information
Type of services your hospital provides (check all that apply)

Other
Percentage of patients that are charity cases
Please describe how your hospital defines charity cases:
Percentage of patients treated free of charge
Number of orthopedic beds in your hospital
Number of total beds in your hospital
Total hips per year
Total knees per year
Please list the implant types currently available at your institution:
Please list the cement types currently available at your institution:
Number of surgeries per week performed by your orthopedic department:
Do you currently have access to the follow services/equipment (check all that apply):
Sterilizer - please list type(s) of sterilizer(s) available
Do you have functioning x-ray in your operating room?
Do you have any experience in arthroplasty?
If yes, explain your arthroplasty experience:
How many hip and knee replacements have you done?
Are you willing to travel to learn World Knee/World Hip technique?
How many surgeons in your department plan to perform joint replacements?
Names and email addresses of surgeons planning to perform TJA surgery
Our ultimate goal is for the local physicians to do the surgery. However, would a visiting Walk Strong consultant be permitted in your operating rooms to perform and assist using the Signature Orthopedic World Knee and/or World Hip implant and other orthopedic products provided by the Walk Strong Foundation?
Permission for visiting Walk Strong consultant in operating rooms
Does your hospital train orthopedic surgeons?
What is your hospital orthopedic infection rate (percentage of cases that develop postoperative infections)?
Please check below which equipment your hospital currently has:
How did you learn about the Walk Strong Foundation?
Hospital Administration and Logistics
The implant company will ship products directly to your hospital. Walk Strong does not pay custom duties nor do we have personnel in your country that will process your shipments through customs. Please describe how your administration affiliated with your hospital will process the shipments through customs, as well as manage inventory and store implants:
How much does your hospital charge a patient to have a hip replacement (without the cost of the implant)?
How much does your hospital charge a patient to have a knee replacement (without the cost of the implant)?
Walk Strong and Signature Orthopedics have a patient/implant registry program. This registry collects patient demographics, surgical and patient-reported outcomes data.
Are you willing to record and track patient information in a registry database?
Are you interested in publishing results?
Additional Comments: Below please provide a brief summary of the following - Program Goals/Objectives, desired long-term relationship with the Walk Strong Foundation, and any barriers (anticipated now or in the future):
Applicant Information & Signature
Printed Name
Email Address
example@example.com
Signature
Date

MonthDayYear
Date
Thank you for submitting your application. It will be reviewed by the Program Selection Committee for acceptance. If your hospital is accepted, you will become part of the Walk Strong Foundation.
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Walk Strong Foundation - Site Application

Contact Information

Orthopedic Information

Hospital Administration and Logistics

Walk Strong and Signature Orthopedics have a patient/implant registry program. This registry collects patient demographics, surgical and patient-reported outcomes data.

Applicant Information & Signature

Thank you for submitting your application. It will be reviewed by the Program Selection Committee for acceptance. If your hospital is accepted, you will become part of the Walk Strong Foundation.