AV Fistula Surgical - Partner Application

PARTNER APPLICATION

AV Fistula Surgical

SECTION 1: CONTACT INFORMATION

Applicant Name *

Applicant Phone *

Applicant E-mail *

Applicant Address *

Address (Line 2)

City *

State

ZIP Code

Country *

Name of In-Country Contact *

Contact Title *

Contact Phone *

Contact Cell Phone

Contact E-mail *

SECTION 2: DESCRIPTION OF FACILITY

Name of primary hospital facility *

How many years has the medical facility been in operation? *

Have you partnered with Bridge of Life before? *

Yes No

Describe the area served by the facility (socioeconomic class, ethnicity): *

How many dialysis units are involved in the surgical project? *

Is transportation to the surgical facility available for patients? *

Yes No

How many patients do you anticipate needing vascular access (arteriovenous fistulas)? *

How will patients be referred for surgeries? *

Are all the patients adults? *

Yes No

If no, what % are pediatrics?

Will the surgeries take place at the primary hospital facility? *

Yes No

How many operating rooms will be available for surgeries?

Are recovery/post-operative facilities available? *

Yes No

Is there an adjacent area for ultrasound screening and pre- op exams? *

Yes No

Are anesthesiology services available? *

Yes No

Are fluoroscopy and ultrasound units available if needed? *

Yes No

If yes, please indicate their (brand/model):

What is the setting of the hospital? *

Urban Rural

Is your medical facility public or private? *

Public Private

Do you currently test for Hepatitis? *

Yes No

Do you currently test for HIV? *

Yes No

SECTION 3:CONTACT INFORMATION OF LOCAL PROJECT LEADERS All local partners need to elect project leaders who will be heavily involved in the planning and execution of the project. These individuals will be actively engaged and need to be committed and engaged throughout the project. Please identify the following roles in this section.

Name/title of In-Country Contact (Administrative Project Leader): *

In-Country Contact Phone: *

In-Country Contact E-mail Address: *

Name/title of In-Country Nephrologist: *

In-Country Nephrologist Phone: *

In-Country Nephrologist E-mail Address: *

Name/title of In-Country Surgeon: *

In-Country Surgeon Phone: *

In-Country Surgeon E-mail Address: *

Name/title of In-Country Head Dialysis Nurse: *

In-Country Head Dialysis Nurse Phone: *

In-Country Head Dialysis Nurse E-mail Address: *

Name/title of In-Country Head Operating Room Nurse: *

In-Country Head OR Nurse Phone: *

In-Country Head OR Nurse E-mail Address: *

SECTION 4: REQUEST FOR SUPPORT

How many individuals will directly benefit from this mission? *

Please describe this specific need in detail. What prevents you from doing the surgeries without support from Bridge of Life? *

Specifically, what supplies are you requesting from Bridge of Life (quantity and type)?

What is your facility able to contribute to the activities or supplies of the mission?

Describe the space available for the medical volunteer team to work (including # of rooms): *

SECTION 4: TRAINING

Please describe any specific training needs for medical staff at your facility related to the mission. *

Approximately, how many people will participate in the training? *

Please describe the participants of the training (background, language, education level, etc.) *

Please describe where the training will be held

Please describe specific training topics that are most important to your facility.

Please describe any patient health education needed.

Please provide any additional information to help us understand your training needs.

LICENSING, CUSTOMS AND LOGISTICS

Are you familiar with local laws and regulations related to customs and importation of medical equipment and supplies? *

Yes No

Have you ever imported any medical equipment and supplies for use in your clinic? *

Yes No

Are you familiar with the process for getting a duty-free waiver for customs duties? *

Yes No

Do you have any partner organizations or affiliations with government officials that can help with the importation process? *

Yes No

Are you familiar with local laws and regulations related to temporary licensing for medical volunteers? *

Yes No

PROJECT SCOPE

Please describe in your own words the need for arteriovenous fistula vascular access for your patients (please include the rate of infections if known). *

What impact will this project have on your patients? *

Please feel free to include any questions you may have about your proposed project or provide any additional information.