Primary Care - Partner Application
Primary Care, Women's Health, Pediatrics, Vaccinations, Training
Address (Line 2)
Name of In-Country Contact
Contact Cell Phone
Name of Facility
How many years has the medical facility been in operation?
Have you partnered with Bridge of Life before?
Describe the area served by the facility (socioeconomic class, ethnicity):
What is the total population served by the facility?
What are the most prevalent diseases?
# of inpatients per day:
# of outpatients per day:
What percentage of patients at your facility are adults?
What percentage of patients at your facility are pediatric?
What are the native languages of the people you serve?
What is the setting of the clinic?
Is your medical facility public or private?
# of doctors
# of nurses
# of admin staff
# of maintenance personnel
How do patients pay for their medical treatment? Please explain any major government health policies that offer free or reduced health care.
List all units at your medical facility (including lab and surgical units).
Describe the preventative health care offered by your facility
How many and what kind of immunizations do you administer to children each year?
How many and what kind of immunizations do you administer to adults each year?
Does the government offer any immunizations free to either children or adults? Please explain.
Please list any specific immunizations that are difficult to obtain at your facility
Please identify which of the following are major limiting factors to achieving quality health care
Please describe in detail these challenges.
REQUEST FOR SUPPORT
Please indicate the type of care you are requesting this medical mission to provide.
Are local doctors and nurses available to collaborate on the mission?
If yes, how many?
What specific medical problem would you like this medical mission to respond to?
Does your facility currently provide treatment for this condition or illness?
How many individuals will directly benefit from this mission?
Please describe this specific need in detail.
Specifically, what activities are you requesting from Bridge of Life?
Specifically, what supplies are you requesting from Bridge of Life (quantity and type)?
Preferred Project Dates
Please provide a tentative schedule for your request (including # of days and major activities that will take place each day)
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):
TRAINING (ALL OF BRIDGE OF LIFE’S MISSIONS INCLUDE PROJECT-RELATED TRAINING OF LOCAL PERSONNEL AS WELL AS OPTIONAL PATIENT EDUCATION OPPORTUNITIES)
Please describe any specific training needs for medical workers 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 the proposed training schedule (length of training, hours each day)
Please list any materials or supplies you can offer to benefit the training
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?
Have you ever imported any medical equipment and supplies for use in your clinic?
Are you familiar with the process for getting a duty-free waiver for customs duties?
Do you have any partner organizations or affiliations with government officials that can help with the importation process?
Are you familiar with local laws and regulations related to temporary licensing for medical volunteers?
Please tell us the specific objectives you hope to achieve? What impact will it have on your community?
Please describe how you will identify the people to receive treatment/training.
Please feel free to include any questions you may have about your proposed project.
Should be Empty: