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ACR Foundation International Outreach Materials Request Form

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.
1.Name of Requestor:
2.Requestor Email:
3.Program or Institution Requesting Assistance:
4.Approximate population served by hospital/clinic:
5.Town/City:
6.Country:
7.Please note the type of institution:
8.To be used for the training of (check all that apply):
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:
10.Video:
11.Computer Operating System:
12.Internet Connection:
13.What radiological capabilities does your institution have? Check all that apply:
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:(Required.)
15.Please provide any supplemental information that you feel would assist the ACR in making a decision:
Please provide pertinent shipping information below:
16.Name:
17.Address
(as it should appear on a shipping label):
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