US Free & Safety Net Clinic Application

Today's Date

MonthDayYear

Name of Clinic*

Contact Person

Contact Person Name*

PrefixFirst NameLast Name

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Title

Address*

County*

Which MedShare Facility is closest to you?*

Email*

ie. name@mail.com

Phone*

ie. 123-456-7890

Fax

Dedicated line?

YesNo

Website

Type of organization*

501(c)3 Non-profit Organization (please furnish letter of determination below)Faith-based OrganizationOther

Upload 501(c)3 letter of determination here

Upload a File

If "Other", please specify

Party Responsible for Costs

Title

Address

Email

Phone

Fax

Has the facility received assistance from MedShare before?

YesNoI don't know

If yes, when?

How did you hear about MedShare?*

List other sources that donate medical supplies and equipment to your facility:*

List all organizations with which you and the facility are affiliated:*

Who owns/operates the clinic?*

What is the legal status of the clinic?*

If Religious, what affiliation?

If other, please describe:

Describe funding of the clinic (i.e. fee for service, donor, government, etc.)*

PLEASE INDICATE THE ANNUAL BUDGETED ALLOWANCE AND ACTUAL ANNUAL EXPENDITURE FOR REOCCURRING MEDICAL SUPPLIES FOR THE MOST RECENT COMPLETE FINANCIAL YEAR. (PLEASE REMEMBER THAT "SUPPLIES" REFERS TO NON-PHARMACEUTICAL AND NON-EQUIPMENT MATERIALS.)

Financial Year (e.g. July 07 to June 08)*

Budgeted Amount*

Actual Expenditure*

Currency of Above Figures

PLEASE INDICATE THE TYPE OF FACILITY (IF THE FACILITY IS OUTPATIENT ONLY, PLEASE INDICATE A "0" IN NUMBER OF BEDS).

Type of Facility*

If Other, please describe:

Number of Beds (if applicable)

How long has this facility been in operation?*

What is the total number of staff at the facility?*

How many of the following are there:

Physicians:

Surgeons:

Laboratory Technicians:

Dentists:

Anesthesiologist:

Nurse Anesthetists:

Traditional Healers

Midwives:

Nurses:

Nutritionists:

Biomedical Technicians:

Community Health Workers:

Other:

Total number of patients the facility treats per month:

Men:

Women:

Total:

0-5 Years Old

Number Inpatients 0-5 yo:

Number Outpatients 0-5 yo:

Total patients 0-5 yo:

6-15 Years Old

Number Inpatients 6-15 yo:

Number Outpatients 6-15 yo:

Total patients 6-15 yo:

16-49 Years Old

Number Inpatients 16-49 yo:

Number Outpatients 16-49 yo:

Total patients 16-49 yo:

Over 50 Years Old

Number Inpatients over 50 yo:

Number Outpatients over 50 yo:

Total patients over 50 yo:

Types of Medical Services Provided at the Facility (check all that apply)*

If Other, please describe:

What are the major health problems treated at your facility? *

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

WHAT CHARACTERISTICS BELOW BEST DESCRIBE THE CLINIC?

Sterilization*

If other, please specify:

Oxygen*

Does the institution have access to the internet? *

Does the institution use Microsoft Windows software? *

Provide a general list of supplies needed. (MedShare does not receive, store or ship pharmaceuticals)*

What is the estimated population size of the geographic area served by the facility?*

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

What are the primary causes of mortality in your area?*

How will the population served by the facility benefit from the medical goods being donated by MedShare?*

In considering medical supply, which situation best describes your facility/organization?

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 adequate supplies for all patient services.The facility often has a surplus of supplies for patient services.

Please list two (2) independent references MedShare may contact. These references must not be directly affiliated with your organization or facility, but need to have knowledge of the services provided. This could include officials, medical professionals, NGOs, past volunteers or other organization within your community.

Reference 1

Contact Person*

Organization

Title

Address *

Phone *

Fax

Email

Reference 2

Contact Person *

Organization

Title

Address *

Phone *

Fax

Email

The medical supplies, equipment, materials and other items available from MedShare are items that would have been discarded or otherwise disposed of by hospitals or health care providers in the United States. These Materials are being made available strictly on an as is basis for humanitarian use in circumstances in which sufficient alternative sources of such resources are not available. The recipient organization recognizes that MedShare and the donor facilities do not make any representations or warranties, either express or implied, as to the condition of the Materials, and further recognizes that MedShare and the donor facilities make no representations or warranties, express or implied, that the Materials are fit, appropriate, free from defects, sterile, pure, operable, or otherwise suitable for any intended purpose. The recipient organization accepts the Materials as is, with all faults, and acknowledges that the inspection for any defects and the safe operation of said Materials is solely the responsibility of the recipient organization. Each recipient organization, recipient facility, and responsible manager of such entities assumes full responsibility for making an independent determination of the appropriateness of the Materials (or any part thereof) before using them, and for discarding any Materials which are not appropriate for use. Under no circumstances shall MedShare, the manufacturer or distributor of the Materials, or any United States hospital or health care provider that ever owned or used the donated equipment, be liable to recipient organization or anyone for any direct, special, indirect, incidental, or consequential loss or damage resulting from the Materials or their use. To the maximum extent permitted by law, the recipient organization fully accepts and assumes all risks and all responsibility for losses, costs, and damages that the recipient organization, its agents, representatives, members, directors, officers, employees, agents, contractors, patients, and transferees may incur as a result of the Materials or their use, including without limitation personal injuries, illness, damage, loss to property, and death.

MedShare and the recipient organization recognize that this agreement shall release MedShare and the donor facilities from any and all liability for personal injury and/or any other type of injury arising from the use of the Materials. The recipient organization acknowledges that the consideration for this release and indemnification is the donation of the Materials themselves. By making an application for the receipt of such Materials and by accepting such Materials, the recipient organization, to the maximum extent permitted by law, fully releases, acquits, and forever discharges MedShare, the donor facilities, and each and every past and present subsidiary, affiliate, officer, director, agent, servant, employee, trustee, and representative of MedShare and the donor facilities from any and all loss, damages, claims, causes of action, suits, debts, liens, obligations, liabilities, demands, costs and expenses of any kind, character, or nature whatsoever, known or unknown, fixed or contingent, which might arise from or be related or associated in any way with the Materials or their use, including but not limited to any injury, illness, disease, property damage, death, or loss of any nature suffered or sustained in connection with the use or possession of the Materials. To the maximum extent permitted by law, the recipient organization also agrees to indemnify, save, and hold the Released Persons and Entities harmless for any loss, damages, claims, causes of action, suits, debts, liens, obligations, liabilities, demands, costs and expenses (including attorneys fees) of any kind, character, or nature whatsoever, known or unknown, fixed or contingent, which may be incurred arising out of or related to the use or possession of the Materials, regardless of the nature or the extent of the injury, illness, disease, property damage, death, or loss, and regardless of whether it results from the negligence of the Users or of the Released Persons and Entities.

Agreement Affirmation

I Agree to abide by the guidelines aboveI do not Agree to abide by the above guidelines

US Free & Charitable Clinic Application

Contact Information

General Information

Facility Information

Community Information

References

Recipient Agreement