Application for Container Shipment from MedShare

Application for Container Shipment from MedShare
Please complete this form to request one of MedShare's 40 foot containers of medical supplies and equipment.
Date*

MonthDayYear
Name of person completing application*

First NameLast Name
E-mail of person completing application*
What organization do you represent?
Shipping the Container
Consignee

This is the organization which appears on official shipping documents as the recipient of the container. In some cases the Consignee is the healthcare institution which will utilize the donated medical supplies. In other cases it is a charitable organization which will receive the container and give the donated medical supplies to a local healthcare institution.
Name of Consignee Organization*
Address EXACTLY AS IT SHOULD APPEAR ON OFFICIAL SHIPPING DOCUMENTS (street, city, state/province, postal code, etc. DO NOT PROVIDE P.O. BOX.)*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
What is the legal status of this organization? *

GovernmentalCharitable OrganizationNGO/Non-Profit (not a charitable organization)Other
If 'Other', please specify:
Is this the healthcare institution which will USE the donated supplies?

YesNo
Comments:
Notify Party

This is the person to whom official shipping documents will be mailed via ground courier. This person will use the shipping documents to remove the container from the port.
Name*

First NameLast Name
Organization
E-mail*
Work Phone*
Mobile Phone*
Fax
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Comments:
What is the ocean port where you wish the container to be sent?*
MedShare ships the container to the ocean port nearest to the consignee. The consignee is responsible for transporting the container from the port to the hospital(s) where the medical supplies will be used.
MedShare requires the consignees to obtain written permission for duty-free import from the appropriate government agency prior to shipment of the container. Do you currently have permission for duty-free import?*
Comments:
What laws does your country have regarding importation of donated medical supplies and equipment? (Check all that apply.)*

Items that expire within a certain number of months may not be imported (include number of months in Comments)"Invasive" items that enter the body may not be importedRefurbished equipment may not be importedEquipment must include manualsAll items must be inspected prior to shippingConsignee must obtain pre-approval of duty-free import prior to loadingOther
If 'Other', please specify:
Comments (including expiration details)
The Healthcare Institution

Please describe the hospital(s)/clinic(s) which will use the donated medical supplies and equipment.
Name of healthcare institution*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Phone Number*
Fax
Website
Contact person at healthcare institution*
Title*
E-mail*
Work Phone*
Mobile Phone
What is the legal status of this healthcare institution?*

Private, for profitPublic/GovernmentOther
How many facilities will utilize the items sent in this shipment? *
Name*
Number of Beds*
What type of area is this healthcare institution located in?*

UrbanRural
How is this healthcare institution funded?*
If Other, please specify
(Required) What is the approximate annual budget?*
In what currency?*
Total number of patients treated:
per month:
per year:*
What are the major health problems in this area?*
What are the biggest problems this healthcare institution is facing?*
How will your patients benefit from the medical supplies and equipment that MedShare sends?*
What electrical voltage is used?

110 volts, 50 Hz110 volts, 60 Hz220 volts, 50 Hz220 volts, 60 Hz60 Hz
How is oxygen delivered?*
How are items sterilized?*

AutoclaveGasOther
If Other, please specify:
Is there running water available?*

YesNo
Is there stable electrical current?*

YesNo
Is there internet access?*

YesNo
What medical services are provided at this healthcare institution? (check all that apply)*

Primary CareGeneral MedicinePediatricsX-ray/Imaging servicesDentalMental HealthFamily PlanningEmergency CareIntensive CareNutritionalSurgeryObstetrics/GynecologyOrthopedicsEndoscopyEye CareOther
If Other, please specify
STAFF

Please indicate the number of each type of staff position at this healthcare institution:
Physicians
Midwives
Biomedical Technicians
Laboratory Technicians
Surgeons
Nurses
Dentists
Community Health Workers
Nutritionists
Anesthesiologists
Other
Other comments about this healthcare institution:
Please identify which of the following two options the healthcare institution prefers to use for making the selection of medical supplies to go on the container:
CHOOSE ONE:

OPTION 1 - A doctor, nurse, or other medical professional from the hospital will order the supplies from MedShare’s online inventory website, using a unique username and password that MedShare will send them. (*Please note, this person must speak English, have good internet skills and a reliable internet connection, and several days available to spend.)OPTION 2 - The hospital will give MedShare a list of the supplies that are needed and MedShare’s staff nurse will make the selection from MedShare’s supply inventory. MedShare will send the hospital a proposed full packing list to review and approve. (*Please note, this is the best option for hospitals with limited internet connectivity.)
OPTION 1 - Name of medical professional who will place the online order:
OPTION 1 - Email
OPTION 1 - Phone
OPTION 2 - Please list the medical supplies that the hospital needs here:
BIOMEDICAL EQUIPMENT REQUESTS

Note: MedShare relies on donations to support our mission. While we will strive to support your hightes priority items to the best of our abilities, please be aware that it is unlikely that we willbe able to provide every requested item.
Select your top 3 priorities from this equipment group.*

Anesthesia machineDiagnostic Ultrasound with probeMicroscope (surgical & lab)Infant IncubatorBlood gas analyzerOR LightOR / Surgical / Delivery tableElectrosurgical unitAutoclave / Sterilizer (tabletop & bulk)ColposcopyEndoscopy equipmentInfant WarmerChemistry analyzerPortable X-Ray machineDental X-Ray machine
Select your top 10 priorities from this equipment group*

Vital sign monitorsCardiac / NIBP MonitorPulse OximeterCentrifugeEKG RecorderCast sawDefibrillator / monitorsExam tablesPatient warmerCoagulation analyzerComputer (desktop)ShakersLab incubatorDermatomeSurgical Head lightX-Ray processor / developerManual Hospital BedElectric Hospital BedInfant cribStretcherFedtal DopplerFetal MonitorHematocritMedical refrigeratorLab washerMicroscope (Binocular)SpectorphotometerWater bath heaterOphthalmic equipmentOtoscope / ophthalmoscopeOxygen concentratorSuction pumpVaporizerVentilatorHyfrecator
Select your top 10 priorities from this equipment group*

Exam stoolsAdult Weighing scalesIV PoleMayo trayCrash cartStethoscopeLaryngoscopeSphygmomanometerComputer monitor (flat screen)CPAP / HumidifierExam lightLab dryerLab precision scaleTraction unitEnteral Feeding pumpInfusion pumpOxygen cylinderGlucose monitor (portable)Sequential compressorX-Ray view box (wall mounted)Syringe pumpNebulizerFurnishingsOther
Check your top priorities

Anesthesia machineCast SawColposcopeComputer Monitors (Flatscreen Only)DermatomeEKG recorder (dual)Endoscopies EquipmentFetal DopplerGlucose meter (Portable) – preferably with test strips and lancetsInfant WarmersLaryngoscopesMicroscope – Surgical and LabNebulizerOphthalmoscopeOR lights – Portable and Ceiling MountedOxygen concentratorPortable X-ray system (including portable mammography)StethoscopesTable – Exam, OR, Surgical and DeliveryTraction unitVaporizersVital Sign monitorsX-ray view boxes (wall mounted only)Water bath heatersShakersLab dryersCoagulations analyzersBlood gas analyzersHaematocritBedsStretchersAutoclave / Sterilizer – Table Top and BulkCentrifugeComputers (Desktop – Pentium III or faster)Defibrillator / MonitorsDiagnostics Ultrasound with probeElectrosurgical UnitExam lightFetal monitorHumidifierHyfrecatorInfant IncubatorMedical refrigeratorMonitor – Cardiac and NIBPNerve stimulatorOphthalmic equipment (slit lamps, etc.)OtoscopesPatient warmersPulse OximeterSphygmomanometerSuction pumpsSyringe pumpsThermometers (digital only)Ultrasound (echography)VentilatorWeighing Scales - Adult, infantsX-ray processors / developersSpectrophotometerLab incubatorsLab washersLab digital precision scalesHumidifier chambersChemistry analyzersMicroscopes (Binoculars)Exam TablesWheelchairsOther
Comments:
If your supply voltage is not 110 V/60 Hz, you may need additional transformers to properly operate the equipment you receive. At your request, MedShare can purchase transformers for you for an additional cost.
Comments
Funding
MEDSHARE IS A NON-PROFIT ORGANIZATION AND ALL OF THE MEDICAL SUPPLIES AND EQUIPMENT WE SEND ARE DONATED. HOWEVER, WE DO REQUIRE FUNDING TO COVER THE COST OF OPERATING MEDSHARE AND THE COST OF SHIPPING.
Please identify the source to provide the funding for this container.
Will the funding be provided by the healthcare institution that will use the supplies?*

YesNo
Organization *
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Phone*
Fax
Web site
Contact person*
Title
Email*
Work Phone *
Mobile Phone
Comments
Have you communicated with a particular member of the MedShare staff prior to this application?
Recipient Agreement
Recipient Agreement*

I guarantee that the supplies I receive as donations from MedShare International, Inc. will be delivered to the Healthcare Institution submitted above to benefit patients in need. I understand that these supplies are donated, have no commercial value, and therefore I will not sell or exchange these items for profit. I further attest that I have read and agree to receive donated items from MedShare according to the stipulations below.
The medical supplies, equipment, materials and other items (“Materials”) available from MedShare International (“MedShare”) are items that would have been discarded or otherwise disposed of by hospitals or health care providers in the United States. These Materials are being made available strictly on an “as is” basis for humanitarian use in circumstances in which sufficient alternative sources of such resources are not available. The recipient organization recognizes that MedShare and the donor facilities do not make any representations or warranties, either express or implied, as to the condition of the Materials, and further recognizes that MedShare and the donor facilities make no representations or warranties, express or implied, that the Materials are fit, appropriate, free from defects, sterile, pure, operable, or otherwise suitable for any intended purpose. The recipient organization accepts the Materials “as is,” with all faults, and acknowledges that the inspection for any defects and the safe operation of said Materials is solely the responsibility of the recipient organization. Each recipient organization, recipient facility, and responsible manager of such entities assumes full responsibility for making an independent determination of the appropriateness of the Materials (or any part thereof) before using them, and for discarding any Materials which are not appropriate for use. Under no circumstances shall MedShare, the manufacturer or distributor of the Materials, or any United States hospital or health care provider that ever owned or used the donated equipment, be liable to recipient organization or anyone for any direct, special, indirect, incidental, or consequential loss or damage resulting from the Materials or their use. To the maximum extent permitted by law, the recipient organization fully accepts and assumes all risks and all responsibility for losses, costs, and damages that the recipient organization, its agents, representatives, members, directors, officers, employees, agents, contractors, patients, and transferees (“Users”) may incur as a result of the Materials or their use, including without limitation personal injuries, illness, damage, loss to property, and death.

MedShare and the recipient organization recognize that this agreement shall release MedShare and the donor facilities from any and all liability for personal injury and/or any other type of injury arising from the use of the Materials. The recipient organization acknowledges that the consideration for this release and indemnification is the donation of the Materials themselves. By making an application for the receipt of such Materials and by accepting such Materials, the recipient organization, to the maximum extent permitted by law, fully releases, acquits, and forever discharges MedShare, the donor facilities, and each and every past and present subsidiary, affiliate, officer, director, agent, servant, employee, trustee, and representative of MedShare and the donor facilities (“Released Persons and Entities”) from any and all loss, damages, claims, causes of action, suits, debts, liens, obligations, liabilities, demands, costs and expenses of any kind, character, or nature whatsoever, known or unknown, fixed or contingent, which might arise from or be related or associated in any way with the Materials or their use, including but not limited to any injury, illness, disease, property damage, death, or loss of any nature suffered or sustained in connection with the use or possession of the Materials. To the maximum extent permitted by law, the recipient organization also agrees to indemnify, save, and hold the Released Persons and Entities harmless for any loss, damages, claims, causes of action, suits, debts, liens, obligations, liabilities, demands, costs and expenses (including attorneys’ fees) of any kind, character, or nature whatsoever, known or unknown, fixed or contingent, which may be incurred arising out of or related to the use or possession of the Materials, regardless of the nature or the extent of the injury, illness, disease, property damage, death, or loss, and regardless of whether it results from the negligence of the Users or of the Released Persons and Entities. Recipient organization agrees to provide MedShare with photos and feedback whenever possible related to how the medical supplies and equipment from this shipment are used. Recipient organization gives MedShare permission to use stories, photos and video related to this shipment for marketing and fundraising purposes.
Should be Empty:

Application for Container Shipment from MedShare

Shipping the Container

Consignee

Notify Party

The Healthcare Institution

Please describe the hospital(s)/clinic(s) which will use the donated medical supplies and equipment.

Funding

MEDSHARE IS A NON-PROFIT ORGANIZATION AND ALL OF THE MEDICAL SUPPLIES AND EQUIPMENT WE SEND ARE DONATED. HOWEVER, WE DO REQUIRE FUNDING TO COVER THE COST OF OPERATING MEDSHARE AND THE COST OF SHIPPING.

Recipient Agreement