Letter of intent regarding the Partnership with "Donăm Plasmă" Association

The form can be completed by hand by downloading and printing it. You can complete it online also, after finalising it, you will receive an email with the data provided. Eyther way, we kindly ask you to send it scanned and signed on office@donamplasma.ro.

Download the form
or
APPLICANT DATA
Contact details
Transfusion Center Name*
Address*
Population served
City population*
County population*
Region population*
Transfusion Center Leader: Name and Surname*
Empowered person: Name și Surname*
Landline phone*
Mobile phone*
Email address*
Performance evaluation
Average annual number of blood donors (average over the last 5 years)*
Average annual number of platelet donors (average over the last 5 years)*
Average annual number of convalescent plasma donors (average over the last 2 years)*
Staff structure evaluation
Total number of employed staff*
of which:
Doctors*
Mid-level health providers*
Auxiliary staff*
Authorizations and certifications*
Upload document*
Maximum file size: 1 GB
Do you benefit of the support of certain LOCAL SPONSORS? (for example: County Council; County Residence City Hall or the City Hall where the Transfusion Center is located; County Hospital or City Hospital)*
If you answer YES to this question, please fill in the fields below for each sponsor (as appropriate).
Contact details
Local sponsor leader: Name and Surname*
Local sponsor's name*
Address*
Landline phone*
Mobile phone*
Email address*
How local sponsors get involved*
Do you benefit of the support of certain PRIVATE SPONSORS from the local community side?*
If you answer YES to this question, please fill in the fields below for each private sponsor.
Private sponsor's name:*
Address*
Private sponsor's leader: Name and Surname*
Empowered person: Name and Surname*
Landline phone*
Mobile phone*
Email address*
He/she is interested in co-financing the investments in the Blood Transfusion Center for the performance of plasmapheresis activity in a percentage of*
⚠️NOTE: This Form of Intent can be initialized and sent not only by the Transfusion Centers, but can also be sent by the City Halls, County Hospitals, City Hospitals only with the consent of the Regional Transfusion Center because the current legislation stipulates that plasma can only be collected in collection units that are part of the national transfusion system, respectively the County Blood Transfusion Centers or the blood transfusion units from hospitals that operate under the County Transfusion Centers.

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