The International Center for Equal Healthcare Access

To request ICEHA’s HIV/AIDS clinical mentors to be a part of your comprehensive HVI/AIDS strategy, please fill out the following application form as thoroughly as possible. An ICEHA representative will contact you directly. Please email if you have any questions about the applications.

Contact person:

Clinic/Hospital/Organization:

Position:

E-mail address:

Address:

Phone Number:

Fax number:

Number of physicians in clinic/hospital dealing with HIV/AIDS and infectious diseases:

Number of nurses in clinic/hospital dealing with HIV/AIDS and infectious diseases:

Number of pharmacists serving clinic/hospital:

Number of HIV-infected patients served by clinic/hospital:

Is antiretroviral therapy (ART) available at the clinic/hospital?
Yes
No

ICEHA solicits, screens, and prepares the pro bono clinical mentors prior to sending them to clinics in developing countries. None of the costs that occur in the US as a result of our screening and preparation process have to be paid for by the clinics in the developing countries. However we do favor that the local clinic, NGOs or MOHs, who request our assistance, pay for the local living expenses of the clinical mentors, including economy plane ticket. Would you be willing to do that?
Yes
No

If you would be willing to pay for the expenses of ICEHA volunteers, do you already have the funds available or would you need to obtain funds? If you would need to obtain funds, please provide an approximate timeline of how long you would need.

Do you have a staff member who would be able to organize local logistics of the program (preparing the clinic sites, organizing lodging and transportation, etc.)?
Yes
No

Would you be interested in having nurse volunteers (without physician mentors)?
Yes
No

Services available to HIV-positive patients:

Very specifically, how can ICEHA help you?

Local organizations currently addressing HIV/AIDS:

How did you find out about ICEHA?