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* ---Urban hospitalUrban clinicRural hospitalRural clinicOther 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?* ---Private, For-profitPrivate, Not-for-profitPublic/GovernmentalReligiousOther 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* ---Gas sterilization processSteam/Heat sterilization processOther If other, please specify: Please select the oxygen system available at your facility* ---Central oxygenBottled oxygenNo oxygen at this 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? Δ