expression of interest form

Transcription

expression of interest form
 Trivandrum Institute of Palliative Sciences (a World Health Organization Collaborating Center), an organ of Pallium India, calls for Expression of Interest from medical institutions in India for undertaking development of palliative care services. The aim of the project is to initiate palliative care in medical institutions which agree to making palliative care an institutional priority. The project will provide limited financial support, training of professionals and offer technical support to the selected institution. All Government or charitable medical college hospitals or other major hospitals and major cancer centres are eligible to apply. Those from states without much development of palliative care services will be given priority. The Institution selected is expected to sign a Memorandum of Understanding with Pallium India. It should identify a doctor and a nurse to undergo a six weeks’ certificate course in Palliative Care at a centre identified by Pallium India. The trained faculty is to start a palliative care service abiding by national standards and following WHO guidelines. Pallium India will bear the expenses for training of a doctor nurse team and will provide technical support, mentoring and monitoring of activities. A monthly modest financial support will be provided for two years in addition to an amount for the conduct of an education/awareness activity. A screening committee of the funding agency and Pallium India will be responsible for selection of centres and for monitoring and evaluation of the project. Interested institutions are requested to fill up the expression of interest form and to send it to [email protected]. All queries may be directed to [email protected] or by post to Pallium India, Arumana Hospital, Perunthanni, Trivandrum 695008. .
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EXPRESSION OF INTEREST FORM
PALLCARE INDIA
1. Name of institution
2. Name of Department
3. Name of person responsible for
the conduct of the project
4. Postal address (with pin code)
5. Telephone and fax number if any
6. Email id
7. Name and postal address of
Director/ Chief functionary of the
institution
8. Telephone number of Director/
Chief functionary
9. Email id of Director/ Chief
functionary
10. Is there a palliative care service in
your institute? (If yes, please
provide the following details)
Yes / No
1. How long has your palliative care
service been functional?
2. Do you have a doctor, nurse or other
professional trained in palliative care?
3. What training has each of them had in
palliative care?
4. Is oral morphine always available in
your institute?
No/Yes (since when?)
Are you agreeable to the terms and
conditions laid out in the proposal and would
you be willing to enter into a memorandum
of understanding for this purpose?
Signature with
Name and designation of person in charge of the project
(Signature is not needed if sent by email.)
Signature with Name of Head of
the institution.
Date:
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