Requisition Form - DAIVIK FOUNDATION / ANNADA

Request Form for Oxygen Concentrators

(A) Requisitioner Details
Name*
First Last
Email*
Phone*
Relationship with the beneficiary/ institution*
(B) Hospital/ Institution Details
Type of Institution*
Public or Private?*
Name of the Hospital/ Institution*
Registration number of the Hospital/Institution
Which state is your hospital/ institution operating from?*
What district is your hospital/ institution operating from?*
Pincode in which your hospital/ institution is operating from*
Address of the hospital/ institution*
Total Number of Hospital Beds*
Total Number of COVID Beds*
Total Number of COVID beds (with Oxygen/ Ventilator Support)*
Additional Number of COVID beds (with Oxygen/ Ventilator Support) required*
Total Number of Ventillators available*
Total Number of Oxygen Concentrators available*
Which of the following oxygen facilities do you have currently?*
How many oxygen concentrators have you received as a donation support in the last 3 months?*
(C) Requirement Details
Which size/ capacity of oxygen concentrators would you be willing to accept and effectively utilise.*
- 10 L
- 8 L
- 5 L
Check all that apply
How many oxygen concentrators do you require?*
Does your organisation have access to all other peripherals like canulas, masks or other items that are required for use of the concentrators?*
Does your organisation have access to medical expertise and experience on how to use oxygen concentrators safely and effectively*
- Yes
- No
How long can you wait for the device(s)?
Do you have any funding support available?
- Yes
- No
(D) Beneficiary Institution Authroised Person Details
Authorised Nodal Person/ Doctor Name*
Authorised Nodal Person/ Doctor Email*
Authorised Nodal Person/ Doctor Mobile Number*
Any other remarks?
Please share a formal request on the letter head of the beneficiary institution signed by authorised person
Drop files here or

Accepted file types: pdf, jpg, jpeg, png, doc, docx.
Acceptable file formats: pdf, jpg, jpeg, png, doc, docx / Maximum size 25MB
Please attach any other supporting document as appropriate
Drop files here or

Accepted file types: pdf, jpg, jpeg, png, doc, docx.
Acceptable file formats: pdf, jpg, jpeg, png, doc, docx / Maximum size 25MB
Name
This field is for validation purposes and should be left unchanged.

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Note: We have limited availability of oxygen concentrators with us and constraint to honour every single request. However, we will endeavour to allocate our inventory basis the urgency of need and availability of devices. The campaign team reserves the right to approve or decline requests depending on the prevailing circumstances.

Request Form for Oxygen Concentrators

(A) Requisitioner Details

(B) Hospital/ Institution Details

(C) Requirement Details

(D) Beneficiary Institution Authroised Person Details