Beads of Courage Flagship Program - Information Intake Form

Beads of Courage Flagship Program - Information Intake Form

Thank you for your interest in starting a Beads of Courage Program at your institution. Please be as detailed as possible while completing it. It helps us learn more about your program in order to meet the needs of the patients and families you are serving with Beads of Courage and will be used to draft the Program Participation agreement between Beads of Courage and your organization.

Completion of this form indicates that your organization is ready to proceed with the process to start a new BOC program. We will forward a draft of the Program Participation agreement and initial invoice within a few weeks of its completion.

The timeline for starting a new program typically takes several months but varies based on the following:
- Completion of this form
- Identifying dedicated commitment from staff to take on program implementation
- Securing funding and making initial payment to Beads of Courage.
- Executing Program Participation Agreement (program licensing, legal agreement)
- Completion of Beads of Courage Ambassador Training (scheduled after the initial payment and fully executed agreement is finalized)

Name of organization/hospital

Please provide the full name of the organization/hospital as it should appear on legal documents.
Main Contact Main Contact First Last
This will be the main staff member leading the execution of this program with the BOC team and will receive any communications needed throughout the process.
Main Contact Email
Main Contact Phone
Organization/Hospital Address Organization/Hospital Address
Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country
Beads of Courage Program(s) Information
Which Beads of Courage Program do you wish to start (check all that apply):

Which Beads of Courage Program do you wish to start (check all that apply): Hematology/Oncology Neonatal Intensive Care (NICU) Cardiac Burn Already licensed to use BOC - expansion to new location Chronic (appropriate for chronic conditions, ICUs, trauma, palliative care, etc...); please specify below:

Please indicate what medical service(s) you are hoping to use Beads of Courage within your facility.

If you are expanding an already licensed program, please also check the program that is licensed to use.
Please specify which BOC programs are already licensed to use at your organization if any:

Please specify which BOC programs are already licensed to use at your organization if any: No existing Beads of Courage Program Hematology/Oncology NICU Cardiac Burn Chronic (please indicate what population this is used with):

Please check all that apply.
Material Shipping Address Material Shipping Address
Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country
Please provide the best address for shipping purposes. This will be used to ship all materials to begin the program after the legal agreement is executed and initial payment is made.
Main Beads of Courage Staff/Ambassador

These are staff that will be the leads of the BOC program at the facility. This may or may not be the same person as listed above. It is preferable to identify at least 2 staff if possible.
Main BOC Staff/Ambassador 1 Main BOC Staff/Ambassador 1 First Last
Main BOC/Ambassador 1 Title and Department
Email
Phone
Main BOC Staff/Ambassador 2 Main BOC Staff/Ambassador 2 First Last
Main BOC/Ambassador 2 Title and Department
Email
Phone
If there are more than 2 main ambassadors, please list them below:
Administration/Leadership

An administrator that oversees all patient/family services in the areas where the BOC program will be used
Name Name First Last
Title/Department
Email
Phone
Hospital/Organization Information

Please thoroughly complete the section below. This allows BOC to assess what will be needed to provide the best Beads of Courage experience when starting a new program, as well as assist us in providing the best cost of starting an new program.
What is the size of the area in your hospital/organization where you hope to begin Beads of Courage?

What is the size of the area in your hospital/organization where you hope to begin Beads of Courage? Small (i.e./Pediatric Unit on one floor of an adult hospital...only one area needs to be equipped with BOC materials) Large (i.e./Major healthcare institutionl needing BOC materials in multiple areas/service-lines)
Please provide the most accurate descriptions of the areas where you would like to start BOC including # of beds, average length of stay, patient demographics, etc...)

If BOC will be used in more than one area/unit, please describe each separately.

Please be as detailed as possible. This will help our staff assess your material needs for the new program and allow us to give the most accurate cost to start the program.
How many patients do you estimate supporting annually with BOC? (guesses are fine!):
Funding
Do you have funding secured to start the program?

Do you have funding secured to start the program? Yes No

Standard cost to start a Beads of Courage Program is $5000 with an additional $500 annual licensing fee. This cost may fluctuate based on the size and needs of the program(s) being started as well as if any additional add-ons are included.
Do you have funding secured to sustain the program annually?

Do you have funding secured to sustain the program annually? Yes No Uncertain

Annual costs to sustain the program will vary depending on the program size and use. Annual costs include the annual licensing dues ($500) along with any material refills needed. These refill items are ordered "a la carte" as needed by your organization. Annual refill costs average approximately $1500-$3000 per year but could be higher or lower depending on you needs. Please factor this in to your future funding/budgeting needs.
If you have an allotted funding approved to start a BOC program, please indicate here: $ Dollars . Cents
Funding Organization:

If you have identified a funding source, please indicate that organization here (i.e/ name of hospital if coming from budget, foundation, sponsor, etc. If there are multiple funding sources, please let us know in the comments section. If you do not know where the funding is coming from please enter "unknown."
Funding Organization address: Funding Organization address:
Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country
Funding Organization Main Contact: Funding Organization Main Contact: First Last
Funding Organization main contact phone: Funding Organization main contact phone: - ### - ### ####
Funding Organization Main contact email:
Funding organization website:

If applicable.
Billing

Please indicate where Beads of Courage should send any billing or invoices.
Billing name: Billing name: First Last
Billing organization

If applicable
Who will be responsible for billing for costs of materials?

Who will be responsible for billing for costs of materials? Hospital/organization budget Funding organization Other Other
Billing address: Billing address:
Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country
Billing phone: Billing phone: - ### - ### ####
Billing email
Will any vendor forms or registrations need to be completed to process orders, invoices, etc.?
If you responded that you will need vendor or registration forms, please enter that contact's name, title, email and phone here if different than billing information:
Preferred method of payment:

Preferred method of payment: Credit card Invoice (then check) Invoice (electronic transfer such as ACH) Establish Maintenance Fund with BOC Other Other

BOC materials are shipped upon payment. Credit card and Maintenance Funds are usually the quickest form of payment.

Maintenance funds are funds paid in advance to BOC which are restricted to your organization.
Optional add-on items

Beads of Courage has several optional items that can be added when starting a new program. Please indicate interest below
Are you interested in adding a Beads of Courage materials cart to your order?

Beads of Courage Mobile Bead Pharmacy Cart to support ease of material storage and program
implementation (additional $500)
Other contacts

If possible, please provide any other pertinent contacts below.
Signatory Name (for legal agreements): Signatory Name (for legal agreements): First Last
The signatory is the person who has authority to sign the program participation agreement which is a legal document licensing the use of the program and is signed by both Beads of Courage and your organization.
Signatory email:
Hospital CEO Name: Hospital CEO Name: First Last
Hospital CEO Email:
Nursing Director's Name: Nursing Director's Name: First Last
Nursing Director's email
Public Relations Representative Name: Public Relations Representative Name: First Last
Public Relations Representative email:
Legal Department Contact name: Legal Department Contact name: First Last
Legal Department Contact email:
Foundation contact name: Foundation contact name: First Last
Foundation Contact email:
Are there any other details that you wish to share about your hospital/organization in regard to starting a Beads of Courage program or do you have additional questions/concerns that need to be addressed?
Thank you for you interest in starting a Beads of Courage program and completing this form.

A member of our program team will be in touch with the main contact listed on this form as soon as possible.

If you have additional questions or concerns that need immediate attention, please contact Beads of Courage Program Team at programs@beadsofcourage.org