Humanitarian Medical Kit Report - Health Partners International of Canada

This report should be completed within 30 days of your return from your medical mission.

HPIC thanks you for your collaboration in spreading health and hope. By providing information on the impact of the donated medicines and medical supplies, you enable us to strengthen the quality of our programming and continue our mission to increase access to medicines and improve health in vulnerable communities.

Name*

Destination Country*

Country

Date of Departure*

Shipment Number

(if known)

Customs

Were there any issues experienced with customs as you brought the medicines into the destination country? How were these issues resolved?

Results

Please describe how the medicines and medical supplies helped the intended beneficiaries

Specify the main health concerns treated with the donated products in the community

What health problems were you unable to treat?

How many people were treated with the medicines and/or medical supplies?

Total Treated

Men Treated

Women Treated

Boys Treated

Girls Treated

Where and how were the medicines and medical supplies stored and distributed?

Please specify the setting (i.e. clinic, hospital, mobile clinic, etc.)

How does the community you served usually obtain healthcare and medicines?

Were the donated medicines able to complement other long-term development efforts in the community?

(such as capacity building, awareness raising, training, etc.)

Questions About the HMK

Were some items not used?

If so, please specify the items

If some items were left behind at the end, who is responsible for their distribution

Can you assure that that medicines will be used before their expiry dates?*

Yes
No

If they were destroyed, please forward HPIC a copy of the documentation certifying the proper handling and disposal of the product. (This is required in order for HPIC to comply with Health Canada and WHO requirements).

Would you consider applying for another HMK in the future?*

Yes
No

If no, why not?

Sharing Your Experience

To submit photos or videos: Email content to [email protected].

Will you, or have you provided photos or videos to HPIC documenting your mission?*

Yes
No

If no, why not?

Have you shared your story through a blog, media outlet, newsletter, etc?

If so, please let us know where we can find this information

Stories

Does any particular patient come to mind that benefited from your care and treatment? Please tell us about this person

(age, illness/complaint, impact the treatment had on him/her, names of the product(s) that were used). Note: Names and details can be changed to respect patient privacy. Please provide photos if possible. Multiple stories are always appreciated.

How did your mission personally affect you and your perception of healthcare delivery in this country?

Feel free to provide a personal story or anecdote.

Confirmation*

By checking this box I confirm all the information in this application is accurate and true.

I, hereby confirm that the information provided above is both accurate and complete. I confirm that I have consulted with the participants as appropriate (Recipient Organization, Physician(s), Carrier(s) and/or Healthcare Facility) before completing this report, and that they understand and agree to the terms of HPIC policies and responsibilities for Special Physician Requests.

HPIC reserves the right to use your photos and stories for publications, the web site and reporting, unless otherwise specified. Please notify HPIC of any privacy and/or security issues that would limit use of this information.