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POCC Components Application

Thank you for your interest in P.O.C.C: the Prosthetic and Orthotic Component Clearinghouse.

P.O.C.C. GOAL: To elevate the quantity and quality of prosthetic and orthotic rehabilitation services everywhere.

P.O.C.C. Objectives:

  • to facilitate the provision of new and used prosthetic and orthotic components to those who do not have access to them
  • to ensure that prosthetic and orthotic donations are used not only to prevent having a detrimental effect on any local prosthetic or orthotic clinics, but to help enhance their level of services as appropriate
  • to provide a means to prevent usable prosthetic and orthotic goods from becoming landfill
  • to provide individuals, manufacturers, distributors and facilities a means by which to receive tax deductions for donations of prosthetic and orthotic goods
  • to illuminate the plight of the disabled around the world who are in need of prosthetic and orthotic services yet who do not have access to them.

In order for your organization to obtain access to the supply of Prosthetic & Orthotic goods, you will need to complete the application and release below. We will then review your application and when approved, you will be sent a username and password to log into our online inventory.

P.O.C.C. GUIDELINES

  • It is strictly forbidden for any items received from P.O.C.C. to be directly sold or re-sold. Use of P&O goods shall be restricted to the provision of prosthetic and orthotic services. Nominal fees for the provision of P&O services are acceptable.
  • Components are to be provided by individuals who are educated & trained in prosthetic and orthotic rehabilitation services. This is to ensure that the P&O goods are being properly and safely applied. Documentation of education/training is required upon request.
  • Your organization is responsible for the cost of shipping, warehouse fees, navigating customs as well as any duties or taxes associated with receipt of P&O goods.
  • As a participant of this project, you are accountable for the P&O goods being provided. As such, we require documentation of component utilization once services have been delivered.
  • Before delivering services in a developing country, it is imperative that you investigate the existing clinical services in that region. We are trying to foster collaboration with and growth of existing prosthetic and orthotic clinical services, NOT competition against them.

(Required) indicates a required field

1. Destination

Please provide information about the institution, facility, or location where you will be utilizing the donated supplies.

If religious, what affiliation?

If other, please describe:

2. Primary Contact

In the section below, please provide information about the primary contact for this donation. P.O.C.C. may contact this person to schedule an appointment to pick up the supplies, or to coordinate shipping of the supplies if necessary. A thank-you letter for any sponsorship donation given to MedShare/P.O.C.C. will be sent to the address provided here unless otherwise requested.

3. Medical Professional Responsible for the Supplies Received

In the following section, please provide the requested information about the medical or allied health professional, either traveling or at the destination facility, who will take responsibility for the donated supplies. If there is no medical or allied health professional associated with your trip, P.O.C.C. may limit the types of supplies we can provide. If the medical or allied health professional responsible for the supplies received is the same as the primary contact person, you may skip this section.

4. Trip Details

Approximately what volume of supplies would you like to request from MedShare? (You can express this figure as number of suitcase loads, number of boxes, maximum weight, etc...)

Briefly describe the nature of your trip

Type of organization to which you belong (if applicable)

What are the estimated number of patients to be treated during this trip?

5. Community Information

What is the estimated population size of the geographic area served by the facility?

Are there other prosthetic and/or orthotic facilities in the region you are serving on this trip?

If known, please describe the primary causes of amputation in your region:

If known, please describe the primary causes leading up to the need for orthotic treatment in your region:

Please describe the population and environment of the area with regard to livelihood, language, cultural history, etc.

6. Shipping and Payment

Please state if these items are going to be picked up from medshare or if not, to which address do they need to be shipped?

How are the shipping expenses, warehouse fees & import duties going to be paid for?

Who is going to facilitate getting the P&O goods through customs (if applicable)?

Will the recipients have to pay for services and if so, how much?

7. Prosthetic & Orthotic Questions

Please describe prosthetic components needed (type of device/component & volume):

Please describe orthotic components/devices needed (type & number or volume):

Who are the prosthetic and/or orthotic practitioners delivering services?

Where were they trained? (Evidence of training may be requested.)

For how long have they been providing P&O services?

How are those who receive services going to receive follow up care?

8. Reference Information

Please provide two (2) English-speaking references that we can contact who are familiar with your program and services.

9. Feedback Information

Have you or other group members received assistance from POCC/MedShare before?

How did you hear about POCC/MedShare?

Any other comments:

10. Recipient Agreement

I guarantee that the supplies I receive, as donations from the Prosthetic & Orthotic Componentry Clearinghouse (P.O.C.C.) will be administered by the medical or allied health professional listed above or by others under his or her direction for the benefit of those served by the institution listed above. I understand that these supplies are donated and as such have no commercial value and that the items are not to be sold, resold or exchanged for profit or gain. I further attest that I have read and agree to receive donated items from P.O.C.C. according to the stipulations below.

Release and Indemnity

The medical supplies, prosthetic and orthotic goods, equipment, materials and other items (“Materials”) available from the Prosthetic & Orthotic Componentry Clearinghouse (“P.O.C.C.”) are items that would have been discarded or otherwise disposed of by hospitals or health care providers in the United States. These Materials are being made available strictly on an “as is” basis for humanitarian use in circumstances in which sufficient alternative sources of such resources are not available. The recipient organization recognizes that P.O.C.C and the donor facilities do not make any representations or warranties, either express or implied, as to the condition of the Materials, and further recognizes that P.O.C.C and the donor facilities make no representations or warranties, express or implied, that the Materials are fit, appropriate, free from defects, sterile, pure, operable, or otherwise suitable for any intended purpose. The recipient organization accepts the Materials “as is,” with all faults, and acknowledges that the inspection for any defects and the safe operation of said Materials is solely the responsibility of the recipient organization. Each recipient organization, recipient facility, and responsible manager of such entities assumes full responsibility for making an independent determination of the appropriateness of the Materials (or any part thereof) before using them, and for discarding any Materials which are not appropriate for use. Under no circumstances shall P.O.C.C, the manufacturer or distributor of the Materials, the International Society of Prosthetics and Orthotics, or any United States hospital or health care provider that ever owned or used the donated equipment, be liable to recipient organization or anyone for any direct, special, indirect, incidental, or consequential loss or damage resulting from the Materials or their use. To the maximum extent permitted by law, the recipient organization fully accepts and assumes all risks and all responsibility for losses, costs, and damages that the recipient organization, its agents, representatives, members, directors, officers, employees, agents, contractors, patients, and transferees (“Users”) may incur as a result of the Materials or their use, including without limitation personal injuries, illness, damage, loss to property, and death. P.O.C.C and the recipient organization recognize that this agreement shall release P.O.C.C and the donor facilities from any and all liability for personal injury and/or any other type of injury arising from the use of the Materials. The recipient organization acknowledges that the consideration for this release and indemnification is the donation of the Materials themselves. By making an application for the receipt of such Materials and by accepting such Materials, the recipient organization, to the maximum extent permitted by law, fully releases, acquits, and forever discharges P.O.C.C, the donor facilities, and each and every past and present subsidiary, affiliate, officer, director, agent, servant, employee, trustee, and representative of P.O.C.C and the donor facilities (“Released Persons and Entities”) from any and all loss, damages, claims, causes of action, suits, debts, liens, obligations, liabilities, demands, costs and expenses of any kind, character, or nature whatsoever, known or unknown, fixed or contingent, which might arise from or be related or associated in any way with the Materials or their use, including but not limited to any injury, illness, disease, property damage, death, or loss of any nature suffered or sustained in connection with the use or possession of the Materials. To the maximum extent permitted by law, the recipient organization also agrees to indemnify, save, and hold the Released Persons and Entities harmless for any loss, damages, claims, causes of action, suits, debts, liens, obligations, liabilities, demands, costs and expenses (including attorneys’ fees) of any kind, character, or nature whatsoever, known or unknown, fixed or contingent, which may be incurred arising out of or related to the use or possession of the Materials, regardless of the nature or the extent of the injury, illness, disease, property damage, death, or loss, and regardless of whether it results from the negligence of the Users or of the Released Persons and Entities.

By hitting the SUBMIT button below, I hereby agree to the terms above.

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