Indigenous Medical Needs Assessment Form
Share information about your organization’s healthcare needs and priorities.
Institution Name
*
Location (City, Region, or Community)
*
Contact Person Full Name
*
First Name
Last Name
Contact Email Address
*
example@example.com
Contact Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Type of Institution
*
Please Select
Clinic
Hospital
Health Post
Traditional Healing Center
Other
What are your current resources? (e.g., staff, equipment, medicine)
What are the main challenges your institution faces?
Please indicate your institution's top priority needs
Additional Comments or Suggestions
Submit Assessment
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