Application for New Projects

To submit an application for a new project proposal, please submit the following form. Contact ICA Foundation for further information about the process. Submit the downloadable project proposal form or use the web form below. Download application as word document

General information

Date *

Receiving country *

General description of the receiving organization and/or the service providing organization (including typical clientele, how many patients seen per month, number of clinic sites, etc.) *

Supply address (including street address and contact person’s name and phone number for courier service)

Number of LNG IUSs requested *

Timetable for importation, training, and launch of service delivery (and time period that you estimate the number of supplied LNG IUS would cover) *

Objective of collaboration with ICA Foundation *

Plans for service provision

What clients will be your priority target for LNG IUS provision (e.g. postpartum women, nulliparous adolescent girls and young women, women with menorrhagia, etc.)

Category of provider (MD, midwife, other) who will be offering the services and training needed, as well as monitoring / supervision planned

Needed infrastructure adjustments, if any

What will the service fee be to clients for insertion of the LNG IUS?

What will the service fee be to clients for removal of the LNG IUS?

Plans for client follow-up

Strategies to be implemented for preventing diversion of the supplied LNG IUSs to the private, for profit, sector

Training

Please visit our website, ica-foundation.org, for training and counselling materials, which you can print directly.

Please confirm that your training(s) will include *
Differences between the copper-IUD and the LNG IUS
Counseling, insertion, and removal techniques, side effect/complication management, follow-up visits
Infection prevention
Ethical issues including informed consent before insertion, and removal by request for any reason
Use of any job aids and client materials developed for the LNG IUS, primarily the Training Manual

For fully effective training, how many of the following training materials would you need at this time? *

Uterus Models:

LNG IUS Demo Products:

Additional information

Are you willing to supply documentation and semi-annual reports required by the ICA Foundation? *
YesNo

Please describe your plans to secure the continuation of the use of LNG IUS?

Administrative contact information (name and contact details)

Administrative Email Address*