Note: This information will be valid for one year. Listing requires at least one staff member to be an IAHPC member.

Through TWINNING hospice/palliative care units can establish communication with another unit elsewhere in the world, to exchange information, reports, teaching materials and modules, research ideas, etc. which may lead to exchange visits by staff members.

Through HOSTING hospice/palliative care units can accept a colleague for training (from medicine, nursing, social work, education, pastoral care, etc) for a specified time period. In the case of Hosting units for visiting fellows, traveling arrangements are to be made between the individual and the units involved, and not by IAHPC.

Please ensure (where applicable) that approval for this application has been sought and granted by senior management.

This form has been prepared for use internationally and some terms may be unfamiliar to you. If in doubt, contact the IAHPC Executive Director here.

Completing this form constitutes an offer but it is not binding on either the applicant or the IAHPC.

Information supplied will be included in directories held by IAHPC and is free for members.

Please complete as fully and accurately as possible.

Mark which of the following categories you want to be listed in:
Twinning Hosting Both:

If you DO NOT want this information to be available to other IAHPC members,
please check here

DETAILS OF UNIT/SERVICE

SENIOR STAFF CONTACTS

Staff Members currently members of IAHPC
(include membership number):

EDUCATIONAL FACILITIES AND LINKS
Educational links with Universities, Medical and Nursing Colleges

CLINICAL LINKS
Links with local and specialist centers

DETAILS OF SERVICES OFFERED

In-patients:   No. of Beds

Admissions per Year   Mean stay   Home Care Patients:

Does the unit operate a "Home Care Program"? Yes   No

No. of referrals per year: Ambulatory/Out-patient care:

Does the unit operate an ambulatory/out-patient service? Yes    No

No. seen per year:

Is there a Day Hospice/Center? Yes   No

Hospital Palliative Care Service

Does the unit operate a hospital palliative care service? Yes   No

No. of referrals per year? No. under care at any one time?

STAFFING OF UNIT

If you are listing as a TWINNING unit, please answer the following:

Do you know of a unit you want to TWIN with? Yes   No

If Yes, Please provide the information for the Twinning Unit:

If No, IAHPC can provide you with several possible twinning institutions from which you may choose from.

If you are listing as a HOSTING unit please answer the following questions.

If you want to be listed ONLY as a TWINNING unit this is the end of the application.
Click here to go to the "Submit Information" button below.

ACCOMMODATION

Can the unit provide basic accommodation? Yes   No

If not, is readily available nearby? Yes   No

Please give an approximate "bed breakfast" tariff per day in US Dollars:$

LANGUAGES

If an overseas colleague was to come to you for experience or for teaching, what language(s) would you expect him/her to be fluent in?

EXPENSES

Would your unit expect the visitor to pay for any expenses different that traveling and living expenses?
Yes   No

If Yes, please list these:

LENGTH OF STAY IN YOUR UNIT/SERVICE

Is there a minimum period you would expect a visitor to stay? Yes   No
If yes, how long?

Is there a maximum period you would expect a visitor to stay? Yes   No
If yes, how long?

Reason for the Visit:

Objectives of the Fellow visit:

Program/Schedule

Please include a detailed budgeting of costs in the host country, including what accommodation and travel expenses can be borne by the host organization or individuals in the host country.

FELLOW INFORMATION

Have you identified the Fellow who you would like to visit your unit?
Yes No

If Yes, please provide the following information:

You are now done click "Submit" below