REMEDY at Duke
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REMEDY at Duke

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REMEDY at Duke REMEDY at Duke Document Transcript

  • REMEDY at Duke Supply Request Application About REMEDY at Duke: REMEDY at Duke is a volunteer program of Duke University Medical Center in Durham, North Carolina, organized to recover usable surplus single-use medical supplies and distribute them via Duke affiliated projects to areas of need overseas (www.duke.edu/web/remedy). The program is modeled after REMEDY at Yale University and is carried out by Duke students and staff volunteers. REMEDY partners with the Duke Global Health Institute’s Duke PLUS program, which coordinates the donation of surplus durable equipment, such as monitors and machines that have been removed from service at Duke Hospital. For more information about Duke PLUS go to http://globalhealth.duke.edu or email: duke-ghplus@duke.edu What REMEDY at Duke can provide: REMEDY at Duke collects mostly single-use, disposable items (see list below). We do not collect medications, IV solutions or other perishable items. Priority for donations is given to Duke-affiliated projects; however, non-profit 501(c)3 organizations unaffiliated with Duke University who provide volunteer medical assistance overseas may also request medical supplies from the REMEDY program. Donations of supplies are subject to availability. The receiving organization must submit this completed information sheet as well as a copy of its 501(c)3 certificate. Receiving organizations are responsible for the loading and transportation of supplies from the Duke University storage site. Although REMEDY at Duke makes all efforts to donate supplies that are usable, clean, and unexpired, Duke University and Duke University Health System accepts no liability for donated supplies and the receiving individual or organization is responsible for ensuring the supplies are safe and appropriate for use in patient care. 1. Instructions: • Complete one form per organization and sign the “Disclaimer and Release from Liability Form.” Your organization should update its contact information as needed, and submit a new Information Request Form every year, before January 30, to be eligible to receive supplies: • Send your completed application to: John Lohnes REMEDY at Duke Box 3338, Duke Medical Center Durham, NC 27710 Fax to 919-681-6357 or email to: john.lohnes@duke.edu REMEDY @ DUKE – INFORMATION REQUEST 1 of 6
  • 2. Contact Information: a. Name of Contact(s) b. Name of Organization c. Address (incl. State and Zip Code) d. Contact Telephone Number e. Contact Email f. Citizenship 3. Information on Receiving Organization: a. Name of Organization b. Type of Organization (e.g. Faith-based; healthcare, education, government) c. Non-profit tax ID# (if applicable) c. Mailing Address d. Website Address (if available) e. Address where supplies will be shipped to f. Brief Description of Organization (mission, scope, funding) g. Date of mission or when supplies needed h. List all countries and cities where equipment and supplies will be distributed REMEDY @ DUKE – INFORMATION REQUEST 2 of 6
  • 4. List of Requested Supplies Please list the supplies you would be most interested in receiving. Donations to your organization are subject to available supplies. Are you interested in receiving supplies on an ongoing basis? ___yes ___no What is the estimated TOTAL QUANTITY/VOLUME of supplies you are requesting? _____________________________ (e.g. 16”x12”x18” boxes, large duffle bags, shipping pallets, etc.) Quantity Special instruction (e.g size, Description of Supplies type or product preference) PROTECTIVE CLOTHING Non-sterile exam gloves (100/box) Sterile surgical gloves (single pair) Surgical face masks (50/box) Goggles/eyeshields (single) Sterile disposable gowns Disposable isolation gowns Surgical caps/bonnets Disposable shoe covers BANDAGE & DRESSING SUPPLIES 2x2 gauze pads 4x4 gauze pads Cotton balls or sheet cotton Cotton tipped swabs Kerlix or Kling gauze rolls Adhesive strips/Band-Aids Stockinette tubular dressing Op-site/Tegaderm transparent dressings Tape (silk, paper or plastic) Plaster cast material Medicated gauze (e.g. petroleum, Xeroform, etc) Ace/elastic wraps Bandage scissors NEEDLES, SYRINGES & IV SUPPLIES 1cc/tubercular/insulin syringes 5 and 10ml syringes 20, 30 and 60ml syringes IV needles Butterfly needles Arterial blood gas (ABG) needles IV catheters IV primary and secondary sets Description of Supplies Quantity Special instruction (e.g size, REMEDY @ DUKE – INFORMATION REQUEST 3 of 6
  • type or product preference) ANTISEPTIC SOLUTIONS Betadine (4oz bottle) Betadine (swabsticks) Alcohol (4 oz bottle) Alcohol (prep pads) Disinfecting wipes (packets) Alcohol foam hand cleanser (aerosol bottle) Peroxide (4oz bottle) WOUND CARE Disposable scalpels & blades Suture (pack) Skin staplers Suture kits Suture scissors Forceps Steri-strips Surgical drapes Chuck pads Surgical towels Plastic basins Bulb irrigation syringes LABORATORY SUPPLIES Specimen containers (cups) Specimen labels Plastic specimen bags Blood collection tubes Vacutainers and butterfly needles Elastic tourniquets Culture tubes Medication cups Quantity Special instruction (e.g size, type or product preference) REMEDY @ DUKE – INFORMATION REQUEST 4 of 6
  • DIAGNOSTIC SUPPLIES Stethoscopes Tongue blades BP cuffs Tape measures (paper) Urine test strips (bottle) Thermometer probe covers (box) DRAINAGE & SUCTION SUPPLIES Suction tubing Suction tips (e.g. Yankauer) Nasogastric tubes (e.g. Salem) Urinary catheters (e.g Foley) Urine collection trays/bags Thoracic/pleural drains Wound drains (e.g. hemovac) ORTHOPEDIC SUPPLIES Splints & Slings Knee immobilizers Plaster casting material Tubular stockinette Cast padding Crutches RESPIRATORY/ANESTHESIA SUPPLIES Endotracheal airways Oxygen tubing and masks Ambi bags/ventilators Suction catheters OTHER SUPPLY REQUESTS (please list) DISCLAIMER AND RELEASE FROM LIABILITY The medical supplies being provided to the undersigned recipient facility by Duke University Health System, Durham, North Carolina, USA are offered as a donation in 'as is' condition and with no expressed REMEDY @ DUKE – INFORMATION REQUEST 5 of 6
  • or implied warranties, including no implied warranty of merchantability or fitness for a particular purpose. These medical supplies are not being sold; they are offered to the recipient facility as a donation made within the charitable mission of Duke University Health System, Inc. The undersigned recipient agrees to exercise caution when removing and handling the donated medical supplies. The recipient agrees to examine and inspect each item to determine its suitability for patient use, and agrees that each item must be sterilized by the recipient facility before use in connection with patient care. The recipient facility agrees that the recipient facility will calibrate and assure fitness for use and accuracy of any calibrated supply. Duke University Health System, Inc. makes no assurance or representation of the sterility of these medical supplies or their appropriateness for use in patient care. The undersigned recipient accepts all responsibility and liability for use or handling of these medical supplies, and shall not seek to hold Duke University Health System, Inc. responsible for the consequences of the undersigned facility's use of the donated medical supplies. Duke University Health System, Inc. makes the donation of these medical to the recipient in express reliance on the terms of this Disclaimer and Release, and the undersigned recipient facility agrees to the principles and terms of this Disclaimer and Release in accepting the donated medical supplies. *Certification of Consignee and End User* The undersigned recipient certifies that articles being provided are for the sole-use of the undersigned recipient as the end-user. The articles will not be exported, sold, transferred, or disposed of to any location other than the ones intended and indicated on this form. Nor will the undersigned recipient transfer the property to any person or entity if there is reason to believe that it may result, directly or indirectly, in a disposition or transfer that is contrary to the statements of this certification. The undersigned recipient will promptly send a supplemental certificate to the US provider listed above disclosing any change of facts or intentions set forth in this statement. AGREED: I am an authorized official to sign on behalf of: ____________________________________________________________________________ Name of Receiving Organization _____________________________________________ _______________________ Signature Date REMEDY @ DUKE – INFORMATION REQUEST 6 of 6