PARTNER APPLICATION
Dialysis Capacity:
Upgrade of Dialysis Clinic
NOTE:
Please fill out this application only if you are requesting an
upgrade
of an
existing
dialysis clinic.
SECTION 1: CONTACT INFORMATION
Applicant Name
*
Applicant Phone
*
Applicant E-mail
*
Applicant Address
*
Address (Line 2)
City
*
State
Please Select
AL
AK
AZ
AR
CA
CO
CT
DE
FL
GA
HI
ID
IL
IN
IA
KS
KY
LA
ME
MD
MA
MI
MN
MS
MO
MT
NE
NV
NH
NJ
NM
NY
NC
ND
OH
OK
OR
PA
RI
SC
SD
TN
TX
UT
VT
VA
WA
WV
WI
WY
ZIP Code
Country
*
Name of In-Country Contact
*
Contact Title
*
Contact Phone
*
Contact Cell Phone
Contact E-mail
*
SECTION 2: DESCRIPTION OF CLINIC
Name of Facility
*
How many years has the medical facility been in operation?
*
How many days per week is the clinic open?
*
Have you partnered with Bridge of LIfe before?
*
Yes
No
Describe the area served by the facility (socioeconomic class, ethnicity):
*
What are the native languages of the people you serve?
*
What is the total population served by the facility?
*
What licenses or certificates are required to open and operate a dialysis clinic in your country?
*
What is the setting of the clinic?
*
Hospital
Clinic
Urban
Rural
Is your medical facility public or private?
*
Public
Private
Number of doctors
*
Number of nurses
*
Number of social workers
*
Number of dietitians
*
Number of administrative staff
*
Number of technicians
*
On average, how many patients are receiving treatment at the clinic per week?
*
How many more patients do you estimate need treatment?
*
What percentage of patients at your facility are adults?
*
What percentage of patients at your facility are pediatric?
*
What is the prevalence in your area of diabetes?
What is the prevalence in your area of cardiovascular disease?
What is the prevalence in your area of hypertension?
What is the prevalence in your area of kidney disease?
Where is the next closest clinic that provides dialysis located?
*
Where is the next closest medical facility located?.
*
How do patients pay for their treatment? Please explain any major government health policies that offer free or reduced health care.
*
Is there a vascular surgeon at the clinic to place fistulas?
*
Yes
No
If not, where is the closest vascular surgeon?
Is there a transplant program associated with the medical facility?
*
Yes
No
If not, is there a transplant program in the country that is available to patients? Please describe:
Do you currently test for hepatitis?
*
Yes
No
Do you currently test for HIV?
*
Yes
No
SECTION 3: DIALYSIS TREATMENT
How will patients be referred to the dialysis clinic?
Is there a lab service available at the clinic?
*
Yes
No
What is the name of the nephrologist associated with the dialysis clinic?
*
How many years has the nephrologist practiced?
Telephone number of nephrologist:
*
E-mail of nephrologist:
Does the nephrologist practice medicine at other medical facilities?
*
Yes
No
How many patients receive chronic dialysis treatment per month?
*
How are patients selected to receive dialysis treatment?
*
What percentage of patients have catheters?
*
What percentage of patients have fistulas?
*
How many total treatments did you provide last month?
*
How many years have dialysis treatments been available to patients at your clinic?
*
How many dialysis stations are in the medical facility?
*
How many dialysis stations are operational?
*
How many dialysis stations are in need of repair?
*
What year were the current machines installed?
*
What type of dialysis machines are in your medical facility? (i.e. Fresenius, Gambro Pheonix, Nipro, etc.)?
*
What type of water system (RO) is in your medical facility?
*
What year was the current water system installed?
*
How often do you run labs on patients?
*
What labs do you run on patients?
*
What medications do you routinely give during dialysis?
*
Who is in charge of the preventative maintenance of the machines?
*
Who is in charge of the water system disinfections?
*
What was your operating budget from last year?
*
How much do you charge per dialysis treatment?
*
Do you have nurses trained in dialysis?
*
Yes
No
Do you have a tech to fix and maintain the machine?
*
Yes
No
Do you have a reuse process in place for dialyzers?
*
Yes
No
If yes, what method of reuse do you currently use?
What is the average number of reuses per dialyzer?
What sterilant do you currently use?
*
SECTION 4: CLINIC OPERATION & BUDGET
Where will the funding for ongoing operation of the dialysis program come from?
*
Is there any government support of the dialysis program at your medical facility? Please describe.
*
How much funding per month do you anticipate receiving from government sources?
*
Do you have any other funding sources for the operation of the dialysis clinic?
*
Yes
No
If yes, how much funding per month do you anticipate receiving from other sources?
Is there a working plan for the dialysis clinic to obtain supplies needed for dialysis after the medical mission is complete
*
Yes
No
If yes, please explain.
Are there any local funding opportunities or groups that Bridge of LIfe could partner with to fund this project (NGOs, corporations, government, etc.)
*
Yes
No
If yes, please explain and provide contact information if available.
How many patients do you anticipate treating per month for chronic dialysis?
*
How many patients do you anticipate treating per month for acute dialysis?
*
Will you have to hire new staff to operate the dialysis clinic?
*
Yes
No
Are there qualified doctors and nurses in the area available to work in the clinic?
*
Yes
No
SECTION 5: CUSTOMS AND LOGISTICS
Are you familiar with local laws and regulations to customs and importation of medical equipment and supplies?
*
Yes
No
Have you ever imported any medical equipment and supplies for use in your clinic?
*
Yes
No
Are you familiar with the process for getting a duty-free waiver for customs duties?
*
Yes
No
Do you have any partner organizations or affiliations with government officials that can help with the importation process?
*
Yes
No
SECTION 6: REQUEST FOR SUPPORT
Please describe why you need to upgrade your dialysis program.
*
Please indicate the type of care you are requesting Bridge of Life to provide.
*
Equipment
Water System/RO
Dialysis Supplies
Reuse/Equipment and Supplies
Training
Other
How many individuals will directly benefit from this project?
*
Specifically, what supplies and equipment are you requesting from Bridge of Life (please specify quantity and type)?
Please tell us your vision for the dialysis clinic. What impact will it have on your community?
What is your facility able to contribute to the activities or supplies of the mission?
SECTION 7: 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 clinic staff
*
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 any patient health education needed
*
Please provide any additional information to help us understand your training needs
SECTION 8: ADDITIONAL QUESTIONS
Please feel free to include any questions you may have about your proposed project.
Submit
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