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50th Event
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50th Event
Short-Term International Program (STIP) Application
Step
1
of
6
16%
Organizer Information
First Name of Contact
(Required)
Last Name of Contact
(Required)
Contact Salutation
(Required)
Name of Partner Organization
(Required)
Contact Phone
(Required)
Contact Email
(Required)
For qualified programs SEE offers donated surgical supplies through Alcon as well as an assortment of surgical supplies that come directly from SEE called SEE supplies.
Contact Mailing Address
I intend to have SEE Request Alcon Supplies on my Behalf
(Required)
Yes
No
Would you like to recieve both the Alcon and SEE Supplies at the Same Address?
(Required)
Yes
No
Notice: For SEE to request Alcon supplies on your behalf please provide a business address for Alcon shipment.
Notice: For SEE supplies request please provide a US address (can be business or residential)
Shipping Address Business Name
(Required)
Alcon Supplies Shipping Address
(Required)
Street Address
Address Line 2
City
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
U.S. Virgin Islands
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
SEE Supplies Shipping Address
(Required)
Street Address
Address Line 2
City
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
U.S. Virgin Islands
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
Notice: If you or a team member have already submitted an Alcon product request or intend to submit an Alcon request independent of SEE through a different 501c3 nonprofit you cannot have SEE process a second Alcon request for the same program. Alcon will only accept one product request per program.
Program Details
Clinic Start Date
(Required)
MM slash DD slash YYYY
Clinic End Date
(Required)
MM slash DD slash YYYY
Departure Date from U.S.
(Required)
MM slash DD slash YYYY
Return Date to US
(Required)
MM slash DD slash YYYY
Location of STIP
(Required)
City
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antarctica
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bonaire, Sint Eustatius and Saba
Bosnia and Herzegovina
Botswana
Bouvet Island
Brazil
British Indian Ocean Territory
Brunei Darussalam
Bulgaria
Burkina Faso
Burundi
Cabo Verde
Cambodia
Cameroon
Canada
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos Islands
Colombia
Comoros
Congo
Congo, Democratic Republic of the
Cook Islands
Costa Rica
Croatia
Cuba
Curaçao
Cyprus
Czechia
Côte d'Ivoire
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Eswatini
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Guiana
French Polynesia
French Southern Territories
Gabon
Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Heard Island and McDonald Islands
Holy See
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Isle of Man
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
Korea, Democratic People's Republic of
Korea, Republic of
Kuwait
Kyrgyzstan
Lao People's Democratic Republic
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macao
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Namibia
Nauru
Nepal
Netherlands
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
North Macedonia
Northern Mariana Islands
Norway
Oman
Pakistan
Palau
Palestine, State of
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn
Poland
Portugal
Puerto Rico
Qatar
Romania
Russian Federation
Rwanda
Réunion
Saint Barthélemy
Saint Helena, Ascension and Tristan da Cunha
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Sint Maarten
Slovakia
Slovenia
Solomon Islands
Somalia
South Africa
South Georgia and the South Sandwich Islands
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard and Jan Mayen
Sweden
Switzerland
Syria Arab Republic
Taiwan
Tajikistan
Tanzania, the United Republic of
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Trinidad and Tobago
Tunisia
Turkmenistan
Turks and Caicos Islands
Tuvalu
Türkiye
US Minor Outlying Islands
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Venezuela
Viet Nam
Virgin Islands, British
Virgin Islands, U.S.
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Åland Islands
Country
Facility Name
(Required)
Host Ophthalmologist
(Required)
Notice: Please note that in order for SEE to submit a Alcon product request on your behalf, there must be a US board certified ophthalmologist participating in the program.
Additional Program Details
Number of Anticipated Surgeries
(Required)
The number of anticipated surgeries for which supplies from SEE are being requested.
What supplies are requested for this program?
(Required)
SEE works to source the surgical and pharmaceutical supplies needed for approved programs, but there may be instances when not all supplies are available.
Cornea & Anterior Segment
Cataract
Glaucoma
YAG Laser
Oculoplastic
Pterygium
Retina
Strabismus
Other
How Many Cornea & Anterior Segment Surgeries Do You Plan on Doing?
How Many Cataract Surgeries Do You Plan on Doing?
How Many MSICS Cataract Surgeries Do You Plan on Doing?
How Many Phaco Cataract Surgeries Do You Plan on Doing?
How Many Glaucoma Surgeries Do You Plan on Doing?
How Many Pterygium Surgeries Do You Plan on Doing?
How Many Strabismus Surgeries Do You Plan on Doing?
How Many Retina Surgeries Do You Plan on Doing?
How Many Other Surgeries Do You Plan on Doing?
How Many YAG Laser Surgeries Do You Plan on Doing?
Please describe other supplies requested
How Many Oculoplastic Surgeries Do You Plan on Doing?
Would any additional equipment need to be borrowed for the program?
(Required)
Yes
No
Please describe additional equipment needed for the program.
Supply Delivery Date (Must be at least 6 weeks from date that all the SEE requirements are fulfilled)
(Required)
Please list the date by which you would need supplies delivered to your U.S. address. (A letter of invitation must be provided to SEE International at least six weeks in advance of supply delivery.)
MM slash DD slash YYYY
Supply Transport
(Required)
Will supplies be transported with the traveling team or shipped via container/freight?
Travel with Team
Shipped
Notice: All SEE International Program requirements must be fulfilled at least 6 week prior to the date you need supplies delivered. To ensure support complete all the requirements further in advance than 6 weeks if possible.
Host Site Information
Level of Familiarity
(Required)
How familiar are you with the ophthalmic capabilities of the country/region in which the STIP will occur?
Unfamiliar
Somewhat Familiar
Very Familiar
Has this site hosted SEE volunteers before?
(Required)
Yes
No
What was the name of the host ophthalmologist?
Which best describes the overall ophthalmic infrastructure in the country/region where the STIP will occur?
(Required)
Options defined as follows:
Beginning:
No resident training program, little government or private support for ophthalmology, limited ability to source ophthalmic supplies, little or no programs for treating impoverished patients.
Intermediate:
Resident training program(s), emerging leaders, coordinated effort to improve, some programs to treat impoverished patients.
Advanced:
Established in-country resident training program(s), empowered leaders, organized in-country programs to treat impoverished patients.
Beginning
Intermediate
Advanced
Which best describes the host site?
(Required)
Options defined as follows:
Self-sufficient:
Provides ongoing care to paying and charitable patients.
Emerging:
Provides care to paying patients only, but lacks the necessary resources to also treat charitable patients.
Supported:
Provides care to paying and charitable patients, but is at least partially dependent upon outside financial support.
Charitable:
Is fully dependent upon outside financial/clinical support to continue operations.
Self-sufficient
Emerging
Supported
Charitable
How large is the population served by this facility?
(Required)
Is there access to pharmaceuticals needed for eye surgery if SEE is unable to provide them?
(Required)
Yes
No
Is the host able to oversee import and customs paperwork and clearance?
(Required)
Yes
No
Can the host provide a Letter of invitation from the Ministry of Health or other government body?
(Required)
Yes
No
Expected Impact
(Required)
Please describe the impact you expect this program to have. SEE emphasizes and supports programs which treat impoverished patients, but also values programs that contribute to the overall improvement of the in-country ophthalmic infrastructure.
Payment for Services Required?
(Required)
Services offered in connection with SEE International are free of charge unless otherwise agreed upon in advance with SEE International. Will the visiting team provide care regardless of a patient’s ability to pay?
Yes
No
Can you please explain how the cost to a patient will be determined and how much the cost would be.
If a patient is unable to pay for services will they be denied care?
Yes
No
How are patients selected for surgery at this site?
(Required)
Please describe any ongoing educational/clinical/advisory interaction with the host site that will occur during and following the STIP:
(Required)
Does the host site have an ophthalmic residency program?
(Required)
Yes
No
How long has the program existed?
How many residents are affiliated with the program?
How many residents has the program graduated since inception?
Notice: All volunteers should refer to the
US State Department website
for information regarding country-specific entry requirements, such as visas and vaccinations. We recommend starting this process as early as possible to avoid delays.
Visiting Team
How often has the volunteer/team visited this site? With what frequency?
(Required)
Medical Volunteer Participants
Volunteer #1 Name
(Required)
Volunteer #1 Email
(Required)
Volunteer #2 Name
Volunteer #2 Email
Volunteer #3 Name
Volunteer #3 Email
Volunteer #4 Name
Volunteer #4 Email
Patient Impact
Is local, high-quality eye care available to this patient population when there is no visiting international team?
(Required)
Yes
No
How are patient outcomes measured at this site?
(Required)
Please describe the post-operative surgical care that will be provided to patients treated during the SEE program:
(Required)
Is there any additional information you’d like to share about this program?
Hidden
Date
MM slash DD slash YYYY
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Our Programs
Toggle child menu
Expand
SEE Vision Care
Medical Clinics
Countries Served
Connecting People to our Cause
Conditions We Treat
Toggle child menu
Expand
Cataracts
Refractive Errors
Glaucoma
Diabetic Retinopathy
Childhood Blindness
Corneal Blindness
Strabismus
How To Help
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VISION 2020 LINKS – USA
Global Medical Libraries Partnership
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