Centers of Excellence Application Form

Thank you for considering the Passy Muir Centers of Excellence program. For your application, please provide the following information and supporting documents and videos to showcase your facility. Prior to beginning the application, you must have all documentation for phase one ready for uploading in one sitting. When submitting for phase two, you will be provided a link by the COE administrator for submission of additional required materials. Please note: There may be file size limitations to the requested documentation. Videos, photos, and presentations will be uploaded to an external link provided by the COE administrator. If file sizes exceed these limitations, please ZIP files, export documentation in smaller file sizes, or compress them.

Name of Facility *

Facility Address

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

Website / URL

Contact Information of Clinical Representative

Phone Number

Email *

Description of your facility, including what makes your program excellent for the tracheostomy and ventilator population and how the Passy Muir Valve is part of your program (approximately 300 words). Write this description as you would want it to appear if posted on a webpage that spotlights your facility. *

Please upload the following required documents. When naming your files, please adhere to the following procedure. Begin with COE, then an underscore followed by your facility name, then another underscore followed by the date of submission. Example: COE_Barlow_4.23.2019 If you are sending more than one file, begin numbering before the first underscore. Examples: COE_Barlow_4.23.2019 COE2_Barlow_4.23.2019

Team Photo

Names, credentials, and titles of persons pictured in team photo

Consents for every person used in any uploaded media.

Download the consents form here, then scan to PDF or graphic file.

Facility Passy Muir Valve policy and procedure (including use of a PMV for patients on mechanical ventilation, if those patients are served in the facility).

Team members resumes or curricula vitae and a 50-word bio of each team member. These should provide evidence of their qualifications to work with patients following tracheostomy or mechanical ventilation.

I, the undersigned, hereby consent for Passy-Muir, Inc., to the use of names, likenesses, statements, quotations, images, photographs, and/or videos from the above-mentioned facility submitted for the Passy Muir Centers of Excellence program. Please type your name to consent for use of all submissions for the COE program.