Chronic Kidney Disease Prevention Program
Partner Application
ORGANIZATION INFORMATION
Organization
*
Organization Website
City
*
Country
*
Applicant Name
*
Profession
*
Phone
*
E-mail
*
Describe your organization, including mission and recent accomplishments. *
Describe the current health services provided.
Who do you serve? Describe the patient demographics.
Who is on your team? Include # of staff members, specific medical specialties, etc.
Describe any specific CKD treatment and/or prevention services offered.
How does your organization measure impact?
COMMUNITY INFORMATION
Describe the sites where you would like to hold the screening events (names of communities, population size, urban or rural, etc.)
What are the primary languages spoken in the surrounding communities?
*
Describe healthcare services available in the communities, including type of services, quality of services and access to lab testing.
Describe access to dialysis treatment in the area (include distance from the participating communities, fee for service, availability of treatment, etc.)
*
What organizations are currently working on CKD prevention efforts in the area? Do you have a partnership with these organizations?
CHRONIC KIDNEY DISEASE PREVENTION PROJECT
What are your goals for a CKD prevention program in partnership with Bridge of Life?
Please describe the support you hope to receive for a CKD prevention program.
How many people do you anticipate screening with this project?
*
What marketing strategies will you use to spread awareness about the screening event(s)?
Will CKD screening be free of charge to all people that attend?
Yes
No
Will the screening event(s) be exclusive to a certain group of people?
Yes
No
If so, who will you target to attend the event?
What materials or services can your organization provide to benefit a screening event? (please check all the apply)
Organization of project logistics
Chairs, tables, tents for screening
(Some) screening supplies
Marketing
Local volunteers
Medical staff
Translators
Transportation for BOL
Lodging for BOL
Meals for BOL
Management of follow-up of high risk patients
Medication for patients
Contribution of funding
Other
Additional information on any contribution.
Describe any health services or support currently available to people identified with CKD, hypertension and/or diabetes in the communities?
Would you like to organize CKD prevention training for local health professionals in your area?
Yes
No
Please provide any additional information to help us understand the training needs.
What Bridge of Life medical volunteers would be most helpful to support the project?
Nephrologists
Renal nurses
Dialysis Technicians
Renal dietitians
Kidney Educators
Social Workers
Other
Can you assist Bridge of Life to obtain custom clearance for screening supplies and equipment?
*
Yes
No
Don't know
Please provide any additional information to understand the scope of the prevention project.
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