FOR SPONSORS  :   Please fill out this form to request a Medical Missions Initiative in your area.

    Medical Mission Initiative (MMI) Request Form

    Thank you for your interest in working with Hospitals for Humanity by sponsoring a Medical Mission Initiative. MMIs are the beginning of an ongoing partnership with you to provide quality healthcare where it is most needed in the world. Please fill out the following application to tell us about your organization. Fields marks with an asterisk (*) are required.

    Requester Information

    Please tell us about the organization requesting the MMI.

    Name of organization*

    Type of organization* (Check all that apply)
    Nonprofit501(c)3 statusFor profitGovernmentalNon-govermental organizationClinic/HospitalReligious/Faith-based organization
    If 501(c)3, please submit letter:

    Organization address 1*

    Address 2

    City*

    State/Province/Region*

    Country*

    Zip/Postal code*

    Organization website

    Contact person

    Name*

    Title

    Email address*

    Phone number* (Please include country code)

    Person who handles costs

    Name*

    Title

    Email address*

    Phone number*

    Sponsor Information

    Same as the organization requesting the MMI.

    Name of sponsor organization*

    Type of organization* (Check all that apply)
    Nonprofit501(c)3 statusFor profitGovernmentalNon-govermental organizationClinic/HospitalReligious/Faith-based organization
    If 501(c)3, please submit letter:

    Sponsor address 1*

    Address 2

    City*

    State/Province/Region*

    Country*

    Zip/Postal code*

    Sponsor website

    Sponsor contact person

    Name*

    Title

    Email address*

    Phone number*

    Person who handles costs

    Name*

    Title

    Email address*

    Phone number*

    Facility Information

    Tell us about the facility where you would like the MMI to take place.

    Facility name*

    Facility type*
    If other, please specify:

    Facility address 1*

    Address 2

    City*

    State/Province/Region*

    Country*

    Zip/Postal code*

    Phone number*

    Facility website

    Who owns/operates the facility?*

    What is the legal status of the facility?*
    If other, please specify:

    Please describe how the facility is funded (i.e. fee for service, donor, government, etc.)*

    Facility contact person

    Name*

    Title

    Email address*

    Phone number*

    Facility details

    Number of beds* (Put "0" if the facility is outpatient only)

    Total number of staff*

    Number of the following staff:

    Physicians

    Surgeons

    Lab technicians

    Dentists

    Anesthesiologists

    Midwives

    Nurses

    Nutritionists

    Other staff

    Number of patients treated each month:

    Men

    Women

    0-5 years old

    6-15 years old

    16-49 years old

    50 and over

    Medical services provided at facility* (Check all that apply)

    Primary health careGeneral medicineOrthopedicsEye careEar, nose, and throatLaboratoryEmergency care

    GynecologyObstetricsX-ray/Imaging servicesDentalMental healthTraditional medicine

    SurgeryImmunizationsHealth educationNutritional servicesPediatricsFamily planning

    How is your facility working to improve its ability to provide medical services?
    Please list any short or long range plans.

    Please select the method of sterilization used at your facility*
    If other, please specify:

    Please select the oxygen system available at your facility*

    Please select the technology HFH will have access to at your facility* (Check all that apply)
    ComputersPrintersPhoto copiersFax machinesInternet access

    Considering medical supplies, which situation best describes your facility?*
    Supplies are not used for patient services at the facility.The facility often lacks general supplies for patient services.The facility often lacks specialized supplies for patient services.The facility often has enough supplies for patient services.The facility often has a surplus of supplies for patient services.

    General supplies needed*

    Specific biomedical equipment needed*

    Please list other sources that donate medical supplies and equipment to your facility.*

    Please list all organizations with which your facility is affiliated.*

    Community Information

    Tell us about the population that will receive treatment during the MMI.

    What is the estimated population size of the geographic area to be served
    during the MMI?*

    Please describe the population and environment of the area with regard to
    livelihood, language, cultural history, demographics, etc.*

    What are the top five diseases/health concerns in the area?*

    In additional to the facility info given above, please describe any other
    available medical care and/or facilities in the area.

    Specific MMI Requests

    Every Medical Mission Initiative is different. As the MMI provider, Hospitals for
    Humanity will make the final determination on the details of the MMI. The more
    information you provide regarding your goals and desires for the MMI, however,
    the more HFH can work with you to make them a reality.

    What diseases/medical issues do you think should be the focus of the MMI?*

    In thinking about your facility and the population to be treated, what type
    of MMI team(s) would best meet your needs:*
    General medical teamSurgery teamOphthalmology teamObstetrics/Gynecology teamDentistry teamPharmacy team

    Please include any other important information below.

    How did you hear about HFH's Medical Mission Initiatives?