ICM and LGH partnership application form

Application to receive MamaNatalie simulators

Please fill out and submit this form to complete your application to receive MamaNatalie postpartum complications simulators.

Only applications for programs in low income countries as defined here are eligible

Name of association

First Name

Last Name

Role

Project name

Project start date

Project end date

Project partners

Countries of implementation

Only applications for programs in low income country are eligible*

Is this project targeting active midwives, midwife students or other?

Number of midwives/ midwife students being trained by this project

Number of institutions being targeted, either number of healthcare facilities or number of schools

Number of simulators requested

To be able to support as many qualified projects as possible, we will as a general rule have to restrict the offer to 1 simulator per 20 people to be trained.

Briefly describe the challenge your project seeks to address.

Describe the project, including the ambitions for the project, and the status of the project today (if started).

Describe how the project will use the donated simulators, and how you see this impacting the project.

How will the project impact maternal and/or newborn health? What change do you expect to see?

What are the opportunities and plans for scaling and sustaining this project? Do you envision a need for additional simulators as part of that scaling?

Have you used the MamaBirthie or MamaNatalie simulator before?

Yes No

Comments

If donated simulators are received, I agree to provide Laerdal with an update on how the simulators are being used and the impact that is being created during implementation and no later than 6 months of project completion. This may include photos, videos, and testimonials, in addition to a narrative report.

We will handle your personal contact details with care as outlined in Laerdal's Privacy Policy.

*Only applications for programs in low income countries as defined here are eligible