Exit this survey

Please note: This form is not meant as a contract to provide materials, but rather as means to identify needs. Due to limited quantities of materials, all donations are made at the discretion of the ACR Foundation.

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* 1. Name of Requestor:

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* 2. Requestor Email:

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* 3. Program or Institution Requesting Assistance:

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* 4. Approximate population served by hospital/clinic:

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* 5. Town/City:

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* 6. Country:

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* 7. Please note the type of institution:

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* 8. To be used for the training of (check all that apply):

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* 9. To be used for the training of (please include approximate number of students):

What technological capabilities does your institution have? Check all that apply:

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* 10. Video:

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* 11. Computer Operating System:

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* 12. Internet Connection:

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* 13. What radiological capabilities does your institution have? Check all that apply:

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* 14. In the space provided, please explain why you are requesting the materials and in what way they will ultimately improve radiological care in the country, town, city, or region:

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* 15. Please provide any supplemental information that you feel would assist the ACR in making a decision:

Please provide pertinent shipping information below:

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* 16. Name:

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* 17. Address
(as it should appear on a shipping label):

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* 18. What documentation does the donation need to have to get through customs? Where should this be placed?

You will be notified of our final decision within 2-4 weeks.
Thank you!

If you have any questions please contact Lauren Alfero:

American College of Radiology
Attn: Lauren Alfero
1891 Preston White Drive
Reston, VA 20191

lalfero@acr.org
(703)648-8956

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