Ethicon Map Medical Mission Program Form – Fill Out and Use This PDF

Ethicon Medical Mission Program

ELIGIBILITY AND GUIDELINES

ELIGIBILITY

MAP International seeks to partner with those who can endorse our vision of a world in which individuals, families and communities have the hope and capacity to build conditions that promote total health. MAP promotes the total health of people living in the world’s poorest communities by partnering to:

•Provide essential medicines

•Promote community health development

•Prevent and mitigate disease, disaster and other health threats

Applicants must be participating in non-profit charitable work.

Eligibility will be determined based on the completed eligibility forms. Continued eligibility will be dependent upon feedback received and adherence to the stated guidelines.

MAP policy does not allow for transport of medicines or medical products to any to U.S. embargoed country, or ones subject to economic sanctions, e.g., Cuba, Syria, Iran and Sudan without the ordering partner providing proof of having obtained the required licensing from the appropriate departments of the U.S. government.

The applicant must provide the following materials:

1.Fully completed eligibility forms:3

A.Partner Profile

B.Project/Mission Profile

Project profile - long-term health development programs

Mission profile – pre-packs, short-term missions

C. Practitioner's Agreement of Responsibility
D. Charitable organizations
♦ U.S. Based organizations - Provide a copy of 501(c)(3) tax	exempt letter issued
by the Internal Revenue Service indicating your status as a charitable or non-profit
organization.
♦ Non-U.S. Based organizations – Document charitable	status in your

country. If exempt from import duties and tariffs, provide documentation of this status also. These may be in the form of letters from appropriate governmental authorities.

2.Additional information as available:

♦Recent Annual Report

♦Descriptive brochure or any other promotional literature about your organization or project

GUIDELINES

1.Limited Stock: Since MAP’s inventory is primarily dependent on donations from the U.S. pharmaceutical industry, the types and quantities of available medicines and medical supplies will vary.

2.Product Use: In compliance with the Food, Drug and Cosmetic Act, as amended, and Internal Revenue Service regulations, all donated products must be used exclusively for the treatment of the ill, needy and infants and may NOT be sold or exchanged for property or services or re-exported. Adequate records must be maintained to document the handling and distribution of all medicines.

All recipients assume full responsibility that all medicines and medical supplies donated for programs outside the United States will be used only for those programs stated at the time of request. NO PRODUCT MAY BE LEFT BEHIND IN THE U.S., NOR BROUGHT BACK TO THE U.S. Recipients must notify MAP International prior to any changes to the original plan and request.

All recipients will be required to submit a detailed plan for the storage and distribution of any unused medicines with a full report of the disposition to be completed upon return.

In the case where product must be destroyed, notification must be given to MAP. The recipient must handle that product in compliance with the original manufacturer’s recommendations and the recipient country’s regulations. Failure to notify MAP may result in loss of eligibility for future shipments.

3.Customs: Clearing Customs is the responsibility of the consignee/recipient. Documents are carefully prepared to assist in this process (e.g. detailed packing list, gift certificate, invoice). MAP International is not responsible for customs charges, fines or taxes. Should product be confiscated by customs officials and not released for its intended use, MAP must be notified as soon as possible.

4. Security: Donations from pharmaceutical and medical supply companies are dependent upon the product being transported and dispensed in a secure manner upon receipt. When making arrangements in other countries, please exercise caution. Shipments to locations in the U.S. for international transport should be opened only AFTER their arrival to the overseas destination.

5.Feedback: All recipients of MAP’s medicines and medical supplies are required to complete and return the delivery confirmation and feedback forms to MAP. Please include human- interest stories and pictures. The feedback information including photographs and stories may be used by MAP International, its donors and mission partners to promote MAP International’s mission and work around the globe. Photos will remain the property of MAP International, will be shared with MAP travel pack donors and will not be provided to other agents or sold for profit.

ETHICON MEDICAL MISSION PROGRAM

MISSION PROFILE

This form must be filled out for EACH Project as Part Two of your Eligibility Process.

Please complete as much of this information as possible.

A. Recipient Information

MISSION PROJECT/CHURCH NAME:

INDIVIDUAL/CONTACT NAME:

Have you received assistance from MAP International before?		YES	NO
If YES, Please enter
ACCOUNT NAME:	ACCOUNT NUMBER:

Please provide the name and position of the qualified health professional authorized to select the medicines, medical supplies and devices for your order.

B. Mission Information

1.	Mission Destination:
	Country	City or Region
2.	Hospital / Clinic:
	Name	Address if Available

3.MAP’s goal is to benefit local communities. Briefly describe the history of your work/ministry in this community/country:

4.What is the goal of this mission and how will the activities enhance self-help initiatives and/or support the long-range development goals of the community being served?

5. Is there opportunity to enable the development of local community healthcare workers? Explain.

1

ETHICON MEDICAL MISSION PROGRAM

PRACTITIONER’S AGREEMENT OF RESPONSIBILITY

Only licensed healthcare practitioners authorized to prescribe may order prescription medicines. All recipients requesting medicines and medical supplies must provide this form completed by the licensed practitioner whose signature, current state license and DEA number are included. MAP verifies with State Medical Boards that all license numbers are current.

By completing and signing this form, the licensed healthcare practitioner assumes full responsibility for medicines and medical supplies provided by MAP International. All medicines and medical supplies are to be used only in mission work outside of the United States of American and in compliance with the US Food, Drug and Cosmetic Act, as amended, and all other applicable US laws and regulations. The practitioner agrees that these medicines and supplies will not be marketed in the United States nor returned to the United States, nor sold or exchanged for property or services. All medicines and medical supplies will be used only in treating the ill, the needy and infants.

If these supplies are lost, misplaced, or stolen prior to arriving at their ultimate destination, report immediately to MAP by phone (1-912-265-6010) or fax (1-912-280-6638).

Date: ___________________________
Type of Licensed Practitioner: MD DO DDS DMD DPM	Other _________________

Please include a copy of your current license or certificate to practice medicine.

_________________________________________________	_________________________________________________
Print Name of Ordering Practitioner	Address of Ordering Practitioner
_________________________________________________	_________________________________________________
Signature of Ordering Practitioner
_________________________________________________	_________________________________________________
State or Country in Which Licensed	Telephone Number
_________________________________________________	_________________________________________________
State License Number/Expiration Date	Fax Number
_________________________________________________	_________________________________________________
DEA Number	Other Contact Number
_________________________________________________	_________________________________________________
Specialty	Country Where Supplies Will Be Used

If prescription medicines are not to be shipped directly to you, the ordering practitioner, the name and address of the individual authorized to receive any prescription medicines under your name must be provided below:

______________________________________________________________________________________

Name

_________________________________________________________________________________________________________

Address

_________________________________________________________________________________________________________

City

State

Zip

Country