Request an MMI 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

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?