Centers of Excellence Application Form

Thank you for considering the Passy Muir Centers of Excellence program. For your application, please provide the following information and supporting documents and videos to showcase your facility. Prior to beginning the application, you must have all documentation for phase one ready for uploading in one sitting. When submitting for phase two, you will be provided a link by the COE administrator for submission of additional required materials. Please note: There may be file size limitations to the requested documentation. Videos, photos, and presentations will be uploaded to an external link provided by the COE administrator. If file sizes exceed these limitations, please ZIP files, export documentation in smaller file sizes, or compress them.

Nombre de la instalación *

Dirección de la instalación

Dirección (línea 1)

Dirección 2

Ciudad

Estado / Provincia / Región

Código postal

País

Página web / URL

Información de contacto del representante clínico

Teléfono

Correo electrónico *

Description of your facility, including what makes your program excellent for the tracheostomy and ventilator population and how the Passy Muir Valve is part of your program (approximately 300 words). Write this description as you would want it to appear if posted on a webpage that spotlights your facility. *

Por favor, cargue los siguientes documentos requeridos. Al nombrar sus archivos, siga el siguiente procedimiento. Comience con COE, luego un guión bajo seguido por el nombre de su instalación, luego otro guión bajo seguido por la fecha de envío. Ejemplo: COE_Barlow_4.23.2019 Si está enviando más de un archivo, comience la numeración antes del primer guión bajo. Ejemplos: COE_Barlow_4.23.2019 COE2_Barlow_4.23.2019

Foto del equipo

Nombres, credenciales y títulos de las personas que aparecen en la foto del equipo.

Consents for every person used in any uploaded media.

Download the consents form here, then scan to PDF or graphic file.

Facility Passy Muir Valve policy and procedure (including use of a PMV for patients on mechanical ventilation, if those patients are served in the facility).

Team members resumes or curricula vitae and a 50-word bio of each team member. These should provide evidence of their qualifications to work with patients following tracheostomy or mechanical ventilation.

I, the undersigned, hereby consent for Passy-Muir, Inc., to the use of names, likenesses, statements, quotations, images, photographs, and/or videos from the above-mentioned facility submitted for the Passy Muir Centers of Excellence program. Please type your name to consent for use of all submissions for the COE program.