Medical Mission Pack Program

Transcription

1 Medical Mission Pack Program For over 125 years, Johnson & Johnson has been committed to improving the health and well-being of mothers and children around the world. With the support of its operating companies, Johnson & Johnson has brought its credo to life. The credo, a one page document written in 1943 by Chairman General Robert Wood Johnson, outlined the Company s responsibilities to the communities in which Johnson & Johnson employees live and work and to the world community as well. Working with key partners, Johnson & Johnson has been able to extend its outreach of programs to support and create a meaningful impact on the lives of thousands around the globe. Johnson & Johnson recognizes that populations in the developing world can benefit greatly from Johnson & Johnson products. Working with a deeply rooted and impactful partnership, MAP International and Johnson & Johnson work to support healthcare professionals improve the lives of many through the Medical Mission Pack Program delivering over 8,000 packs since Any individual embarking on a medical mission trip is eligible to receive a Johnson & Johnson Medical Mission Pack. All Health care professionals (defined as those who provide, supervise, or manage patient care or those in training for a health care profession) who qualify can receive a Johnson & Johnson Medical Mission Pack Plus (containing a mix of over the counter (OTC) and prescription product). Please see below for further eligibility details. Medical Mission Pack The Medical Mission Pack contains all over-the-counter medicines and supplies. Any individual who plans to travel on a medical mission is eligible to receive a medical mission pack. Eligibility will be determined based on completion and review of application forms submitted to MAP International. Due to product availability, only one pack may be shipped a year per individual. It is required for all individuals who received a Medical Mission Pack to submit a completed online survey when they return from their trip. Please keep this survey in mind when traveling. Medical Mission Pack Plus The Medical Mission Pack Plus contains a variety of over the counter medicines, as well as prescription medication. Only Health Care Professionals (those who provide, supervise, or manage patient care or those in training for a health care profession) are eligible to receive a Medical Mission Pack Plus in order to administer these prescription products appropriately. Eligibility will be determined based on completion and review of application forms submitted to MAP International. Due to product availability, only one pack may be shipped a year per individual. A signature of a physician will be required to be on file as well. This signature will be accepted via fax or scanned document sent via . All licenses are verified against current databases. It is required for all individuals who received a Medical Mission Pack to submit a completed online survey when they return from their trip. Please keep this survey in mind when traveling Glynco Parkway Brunswick, GA Phone: Fax: custsrvc@map.org

2 Packaging These product packs are designed for convenience, can be checked as luggage, and are accompanied by a Customs Paperwork and Packing List allowing for easy navigation through Customs. The packs contain a variety of products for general clinical use. The product inclusion and quantity are subject to availability. MAP Policy does not allow for transport of medicines or medical products to any U.S. embargoed country or ones subject to economic sanctions, e.g., Syria, Cuba, North Korea, Iran, DPRK, and Sudan. Payment The medical mission packs and the bulk of the actual handling expenses required to distribute them are contributed by Johnson & Johnson in the interest of providing better health care for medically underserved persons. To offset the remaining handling costs, there is a non-refundable, tax-deductible service shipping fee of $15 and management fee of $50, for a total of $65 per pack, payable directly to MAP International. Johnson & Johnson funds all products within the packs, the $65 shipping and management fee is simply the difference of the amount required for MAP International to ship the pack and the amount Johnson & Johnson funds for shipment. Fees resulting from the need for expedited shipping services are the responsibility of the recipient. Once final review of criteria for partnership is confirmed, your request can be shipped within two days or as necessary to meet your delivery deadline. Other Available Programs Ethicon Medical Mission Packs are for licensed physicians only and allow for an individual to choose up to 50 specific medical tools most appropriate for individual s medical mission trip. Please refer to the following website for information about the Ethicon Medical Mission Pack: MAP also recognizes that some mission trips require a range of products that is broader than that offered in the Johnson & Johnson Medical Mission Pack Program. Therefore, we would like for you to be aware of MAP's medical mission pack program which is part of an independent program created and administrated by MAP International. More information can be found at MAP s website at Glynco Parkway Brunswick, GA Phone: Fax: custsrvc@map.org

3 4700 Glynco Parkway Brunswick, GA Phone: Fax: Eligibility Requirements MAP International seeks to partner with those who 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 Prevent and mitigate disease, disaster and other health threats Promote community health development Applicants must be participating in non-profit charitable work. MAP complies with U.S. export controls and screens all applicants against government-published lists prior to releasing any shipment. Applicants must secure sufficient funding to cover MAP service fees, shipping costs and any charges related to customs clearance. The applicant must provide the following materials: Fully completed eligibility forms Letter of recommendation, either from a partner organization or an appropriate personal reference Proof of charitable, non-profit status (if applicable) Additional information as available: Recent annual report Descriptive brochure or promotional literature about your organization or project Eligibility to receive donated medicines and supplies will be determined based on the completed eligibility forms. Continued eligibility will be dependent upon reports received and adherence to the stated guidelines. MAP policy does not allow for transport of medicines or medical products to any 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. 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

4 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. All prescription medicines must be prescribed on-site by a qualified medical professional only. 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. or brought back to the U.S. at the end of the mission. 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. All dated medicines and products shipped by MAP must be dispensed prior to their expiration date. 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. All MAP partners must immediately report any adverse event potentially related to MAP-supplied medicines, supplies and/or products by calling MAP International at (912) and ing or faxing the completed Adverse Event Report form to kjohns@map.org or (912) 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. Please exercise caution when making arrangements in other countries. Shipments to locations in the U.S. for international transport should be opened only AFTER their arrival to the overseas destination. 5. Service Fee: Service fees are established for all shipments to recover a portion of MAP s total annual cost to procure, receive, inventory, audit, process, and ship the donated and/or purchased medicines/supplies. 6. Reporting: All recipients of MAP-supplied medicines and medical supplies are required to complete and return the delivery confirmation form and submit distribution and impact reports to MAP, including human-interest stories and photographs. The submitted 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 donors and will not be provided to other agents or sold for profit.

5 4700 Glynco Parkway Brunswick, GA Phone: Fax: Type of Application (Choose One) Organization or Church Individual Name of organization: Name of primary contact: Name of applicant: Organizational affiliations: Address: City: State: ZIP: Phone: Fax: Have you received and read a copy of MAP International s Eligibility Requirements and Guidelines? Do you have experience in clearing medicine through customs to avoid confiscation or paying duties/taxes? Signature of Agreement for Acceptance and Distribution By signing this statement, the undersigned agrees with MAP International s Mission and Vision statement and all conditions of service as explained in the Eligibility and Guidelines, including, but not limited to, the following: 1. All donated product received from MAP International will be used exclusively in charitable work outside the U.S. and in the designated country only and will not be re-exported either to the U.S. or a third country or transferred in exchange for money, other property or services. Violation of this condition may result in prosecution to the fullest extent of the law and/or civil suit. 2. All non-delivery/non-distribution of product due to damage, customs problems or excess amount will be reported to MAP immediately. 3. All dated medicines and products shipped by MAP must be dispensed prior to their expiration date or destroyed in accordance with the original manufacturer s recommendations and the recipient country s regulations. 4. In case of a product recall, all recipients will adhere to MAP s recall policies and procedures. Yes No Yes No Do you have funding to cover service fees and shipping costs, if applicable? Yes No 5. All MAP partners must immediately report any adverse event potentially related to MAP-supplied medicines, supplies and/or products by calling MAP International at (912) and ing or faxing the completed Adverse Event Report form to kjohns@map.org or (912) All recipients of MAP-supplied medicines and medical supplies are required to complete and return the delivery confirmation form and submit distribution and impact reports to MAP, including human-interest stories and photographs. The submitted 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 donors and will not be provided to other agents or sold for profit. 7. MAP International reserves the right to review continued partnership eligibility based on compliance with reporting requirements and adherence to the stated guidelines. Applicant/Contact Name: Organization Name: Applicant/Contact Signature: Date:

6 4700 Glynco Parkway Brunswick, GA Phone: Fax: Section A: Partner Information Date: Have you received assistance from MAP International before? Yes No If YES, please provide the following: Account Number: Account Name: Section B: Project Information Country: City or Region: Product Donation Sites please indicate the number and types of sites where donated medicines will be used: Hospital Church Clinic School Mobile Clinic Orphanage Other (please specify) Intended beneficiaries of the medical aid (check all that apply): Infants & Young Children (0-4 yrs) Adults (20-59 yrs) Children & Adolescents (5-19 yrs) Elderly (60+ yrs) List any in-country partners, both agencies and individuals: Section C: Medicines and Supplies Transportation and Storage Plan How will donated medicines and supplies be transported from the US? Air freight Hand carry as baggage Other Have you complied with all US export license requirements, if any? Yes No Section D: Medicines and Supplies Distribution Plan Describe how the medicines and supplies will be handled and distributed in the country of destination: Will only be handled and dispensed by the mission team on this trip. Will be handed over to licensed facilities and/or health professionals for ongoing healthcare. Other explain: Since unused medicines and supplies cannot be brought back into the U.S., where will unused medicines and/or supplies be stored and how will they be used? (check all that apply): Donated to a licensed healthcare facility and/or health professional for ongoing healthcare. Properly stored by local organization for future medical missions. Disposed according to local governmental requirements when past expiration date. Other explain:

7 4700 Glynco Parkway Brunswick, GA Phone: Fax: Donee Name: Date: Donee hereby accepts responsibility for export clearance and export license determination requirements with respect to all transactions between MAP International and Donee. Donee or its duly authorized agent in the United States shall be deemed the exporter for purposes of all applicable U.S. laws. This acceptance shall remain in effect until cancelled in writing by Donee and written notification of such cancellation is received by MAP International. Without limiting the foregoing acceptance of export compliance responsibility, Donee agrees to comply with all applicable U.S. economic sanctions and export control laws and regulations, including the U.S. Export Administration Regulations and U.S. Treasury Department economic sanctions regulations. Donee covenants that it shall not -- directly or indirectly -- sell, export, reexport, transfer, provide, donate, divert, loan, lease, consign, or otherwise dispose of any items received from MAP International to or via any person, entity, or destination, or for any use prohibited by the laws or regulations of the United States or any other applicable jurisdiction without obtaining any and all prior governmental authorizations required by law. Notwithstanding any other agreement, neither Donee nor MAP International shall take or refrain from taking any action prohibited or penalized under the laws of the United States or any applicable foreign jurisdiction. Donee s breach of this covenant shall constitute cause for immediate termination of the Agreement between the parties. Donee agrees to indemnify and hold harmless MAP International and its affiliates for Donee s noncompliance with these controls in connection with the items. This covenant and all remedies provided in relation thereto shall survive termination or cancellation of this acceptance of responsibility. To ensure that MAP International has complete records with respect to such transactions, Donee shall, at MAP International s request, provide MAP International with copies of any and all export documents, including export licenses or other bases for export authorization and the Shippers Export Declarations or AES records filed, with respect to any transactions in which Donee has received items from MAP International. [Donee Name] [Signature] [Print Name & Title] [Date]

8 DONATION ORDER PAYMENT TRAVEL SHIP TO ACCOUNT CONTACT Acct #: Order #: Offer #: TT: Ship Date: ETA: MAP Account Name: Johnson & Johnson Medical Mission Pack ORDER FORM MAP International 4700 Glynco Parkway Brunswick, GA Customer Relations: Fax: All individuals who receive a Medical Mission Pack are required to complete an online survey when they return from their trip. Please keep this survey in mind during your travels. MAP Account #: Name: Phone: Fax: MAP Use TRAVEL DESTINATION City/Region: COUNTRY: MEDICINE/SUPPLIES DESTINATION Hospital/Clinic: Name: Street: City: DEPARTURE DATE: State: ZIP: RETURN DATE: Phone: Payment must accompany your order. Service fee is tax deductible. Packs may not be returned for a refund. Check (note account name on check - if faxing order, include copy of check) MASTER CARD VISA AMERICAN EXPRESS DISCOVER Card #: Expiration Date: Card Holder s Name: Security Code: Card Holder s Billing Address: Service Fee Quantity Service Fee Total Medical Mission Pack (OTC) $65 X = $ Medical Mission Pack Plus (Rx) $65 X = $ *** JOHNSON & JOHNSON LIMITS INDIVIDUAL MEDICAL PROFESSIONALS TO ONE MEDICAL MISSION PACK PER CALENDAR YEAR *** Any additional donation to help support MAP s medicine programs is very much appreciated. If you wish to contribute, please indicate the extra amount here: $ Thank You!