PROJECT C.U.R.E.
10377 E. Geddes St., Ste. Please return Advance Survey to the
200 following:
Centennial, CO 80112 Field Assessments Manager:
Tel: +1 (303) 792-0729 assessments@projectcure.org
Fax: +1 (303) 792- +1-720-490-4002
0744
Greetings from Project C.U.R.E.! We are looking forward to our upcoming needs
assessment visit. In preparation for the visit, please complete this form and have it
ready for submission to the Project C.U.R.E. Needs Assessment Representative upon
their arrival. Thank you!
Facility Name: Hirna Primary Hospital
Complete Address: Hirna West Hararghe zone Region Ethiopia
Phone /mobile(include country code): 0982614996/0913311500
Email: dawid__________________________________________
Medical Facility Representatives
List the primary contact person that has agreed to complete surveys and follow-up
information sent by PROJECT C.U.R.E. Primary ContactContact Name:
-----------------
Title:
Email:
Phone/Mobile: Alternate Contact #1Contact Name:
Title:
Email:
Phone/Mobile: Alternate Contact #2Contact Name:
Title:
Email:
Phone/Mobile:
C. Demographic Data
Urban Rural
1. Geographical area served by the facility(check boxes) _____
_____ Peri-urban __
2. Socio-economic groups served by the facility (e.g., education, ,
and occupation)
Income,
3. Military persons or veterans served by facility (check boxes)
_____ No _____ yes
4. Population size served by the facility ___________________
700,000
5. How are patients transported to the facility (motorcycle, auto, ambulance,
self-transportation, etc.)?
6. Percent of total patients that are Male 53 % Female 47 %
64,000/year
7. Percent of total patients within each age range
Pediatric (0 – 17 years) 32 % Adult (18 years – 59 years) 51% Senior:
(60+ years) 13%
8. Number of medical facilities within 5 km of this site Number of
hospitals 0 Number of clinics _____
9. Percent of total patients referred to another facility per month for reason
of Specialty Care _____ 12% Overflow % Other 0 % Total 12 % Notes:
D. Description of Medical Facility
Type of Facility (select one type; check boxes)
1. Health center, clinic, or post _____
2. Maternal and child health clinic _____
3. General,provincial,orDistrict hospital
4.Referral,specialty,or t eaching hospital_____specify specialty:
5.main funding source
public private____
Capacity facility
1. Total number of existing beds 60 Additional capacity? If yes__
2. Average occupancy rate 80% past 3 months
3. Number of outpatients treated 64864 per month_/or per year_ 54005/month
4. Number of inpatients treated 3584 per month____/or per year-298/month
5. Number of births 2330/years per month 194 month or per year-percent of
cesarean births:___%
6. Is storage available for consumbles? One site__off site____non available__
7. Can patient consumables be re-supplied froman in- country source?
Yes_____no_______
Infrastructure of Facility
1. Number of Dental suites No 5. Number of Intensive care Units----2
2. Number of Delivery Rooms 4 Rom 6. Number of Laboratory Rooms-----2
3. Number of Emergency Room 5 7. Number of Operating Theatres/Room=2
4. Number of Exam/Consultation Room 1 __________Notes:
E.Description of Medical Staff
1. Number of Doctors 7
a.General/primary
____
b.pediatrics ______
C. OB/GYN _______
2. Number of surgeons ______
a.General 1
b.OBS/GYN 1
C.orthopedic ____ 4. Number of Nurse’s Aides 2
3.Number of Nurses 52 5. Number of Midwives 14
6.Number of Biomedical Technicians 2
7. Number of Laboratory Technicians 8
8.Number of Anesthesiologists/
Nurse Anesthetists 3
9.Number of Dentists/ 0
Notes:
Dental Technicians 1
Medical Disciplines / Services (check boxes) 10.Number of
community Health worker 0
1. Internal Medicine, _____ 8.Laboratory services
General 9.Neurology NO
a. Cardiology, invasive _____ Notes
b. Cardiology, non- _____
invasive 10.Nutrition/Dietician 0
c. _____ 11.OB/GYN/GYN yes
Endocrinology/Rheumat (Anental yes obstetric yes New
ology born yes
d. Gastroenterology _____
12.ophthalmology No
e. Infectious _____
Disease/Immunology 13.Orthopedic No
f. Nephrology (Dialysis) _____
14.palliative care/Hospice Discipline No
g. Oncology _____ 15.pathology No
h. Pulmonology _____
16.pediatrics Yes
2. Dental 0
17.primary/General/Family No
3. Dermatology 0
4. Diabetes Services yes 18.psychiatry/ mental health Yes
5. Ear/Nose/Throat No 19.Radiology Yes
HIV/AIDS Services Yes 20.Rehabilitation Therapy No
21.Respiratory Service Yes
6.
Immunizations/ Yes 22.Tuberculosis Services Yes
7. Vaccinations
G. Surgical 23 Urology Yes
Specialties(check 24.Other(List disciplines below)____
boxes)
1.cardiac/Thoracic ……
N0 Note:
2.Neurosurgery………..
NO
3.Vascular……………..N
O
4.pediatric…………..NO
H.Endoscopy(check
boxes)....NO
Note:
1. Arthroscopy (Joint) NO
2. Colonoscopy (Colon) NO
3. Cystoscopy (Bladder) NO
4. Gastroscopy (Stomach) NO
5. Laparoscopy (Abdominal)
NO
6. Laryngoscopy (Throat) NO
7. Sigmoidoscopy (Lower Colon) NO
Caseload Information( Mark answers with High (H), Medium (M), Low (L), or Not
I. Applicable (N/A ))
1. Asthma/Allergy M 10. Maternity Care L _____
2. Diabetes M 11. Parasites, other**M _____
3. Diarrheal Disease M ( Circle applicable diseases from list
below )
4. Epidemic Concerns* M 12. Pediatrics M
(Circle applicable diseases from list below) 13. Respiratory Infections _____
5. Heart Disease M 14. Trauma/Accidents, traffic M
6. HIV/AIDS L 15. Trauma/Accidents, violence M
7. Hypertension M 16. Trauma/Accidents, work related L
8. Malaria L ______ 17. Tuberculosis (TB) M
9. Malnutrition M
*Epidemic Concerns: Ebola, Meningitis, Cholera, Yellow Fever, Zika Virus, Lassa,
Leprosy, Typhoid, and Covid-19 **Parasites, other: Soil-transmitted Helminthiasis
and SchistosomiasisNotes:
J. Technical Support & Electrical Capacity (check boxes)
1. Is there a Biomedical Technician Yes _____ No _____
available?
a. If yes On site _____ Outsourced _____
b. If outsourced From where ______________ How often
_____________
2. Is there a budget to pay the Yes _____ No _____
technician?
3. What biomedical manufacturer brands are able to be serviced and
maintained using local in-country resources? _______________
_______________ _______________ _______________
4. Can necessary supplies be sourced in country? Yes _____ No _____
5. Type of power? Grid ____ Generator _____ Solar _____
6. Is the electricity reliable? Yes _____ No _____
7. Is there a backup generator? Yes _____ No _____ Is fuel accessible? Yes
_____ No
8. Are step-down transformers Yes _____ No _____
needed?
*only 110 volt / 60 cycle equipment is available
9. Does this facility have access to internet?Yes _____ No _____ If yes, give
details: _________________
10. How is medical waste disposed of? Incineration ____ Placed in Landfill
____ Other ____ Notes:
K. Financial Data
1. How is the facility financed?
a. Patient fees _____%
b. Government contribution _____%
c. Missionary/Sponsor 0%
2. Names of other local or foreign potential partners (e.g.: financial services,
equipment or supplies, etc.)
3. Percent of annual budget spent to purchase medical consumables _____%
4. Percent of annual budget spent to purchase medical equipment _____
%
5. Describe fundraising efforts (past / present / future):
6. How might the donation of medical equipment and consumables influence
the facility’s budget allocation?
L. Top Important Needs
(Prioritize 1= most important)
Responses limited to medical items of equipment, instruments, and
consumables that Project C.U.R.E. can provide.
1. ___________________________________________________________________________
___________
2. ___________________________________________________________________________
___________
3. ___________________________________________________________________________
___________
