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Section 1 of 3
The Frontida Fellowship Initiative Application
Frontida is a nonprofit organisation with the mission to provide accessible digital health applications (such as electronic health records) to medical teams around the world. To accomplish this goal,  we build low-cost applications designed to be simple, customizable, and usable in any location. We know from first-hand experience that the need for a simple health documentation platform is urgent and we would love to chat with you to see if we can help.

The Frontida Fellowship Initiative is a program that provides reduced pricing to medical clinics who could benefit from our applications, but may not have the resources to fund these applications. These clinics must be serving in a rural, developing, or underserved community. If you are a clinic in need of financial assistance, please fill out the form below. For clinics that do not qualify for this scholarship, we also offer an affordable custom options. Contact team@frontidarecords.org for more information.
Organization Name
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Organization Status and Tax ID
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Website (URL)
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Annual Operating Budget
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Organization Operational Location
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(City / Region, Country)
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Are you an organisation or person on the the OFAC List of Specially Designated Nationals and Blocked Persons?
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Yes
No
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add "Other"
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Check the boxes that apply: Does your organization have access to
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Internet / Wifi (in the field)
Internet / Wifi (at headquarters)
Electricity / Power Source
Tablets / Computers / Mobile Devices
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add "Other"
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Annual Number of Patients Served (on average)
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Does you organization serve patients in rural, developing, underserved, or low-resource communities?
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Yes
No
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add "Other"
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What type(s) of health care does your organization provide? (emergency, paediatric, primary care etc.)
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What languages would your system need to be in? You can list multiple lanuages.
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What type of health providers need access to the electronic health record system? Please select from the following list:
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Physicians
Specialist
Mental Health Personnel (psychiatrist/psychologist/therapist)
Pharmacists
Health Educators
Nurse/Nurse Practitioner
Volunteers/Intake Personnel
Technicians
Administrator
Physician Assistant
Social Worker
Other
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add "Other"
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If other, please explain:
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What is the current method being used to collect the health records of patients?
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Electronic Health Records System
Paper Records
Not currently collecting patient records
Other
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add "Other"
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How many health providers would need access to your applications/system?  (How many user account would you need?)
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Please explain how much funding your organization needs to use Frontida's applications? (i.e. My organisation can only pay $X yearly for Frontida's services. We need funding to pay for software development, licensing fees, training, etc.)
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Option 1
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add "Other"
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Section 2 of 3
Goals and Aims
Why are you interested in being a part of the Frontida Fellowship?
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Provide an overview of the region you operate in, your clinic, clinicians, and the population you currently serve. What amount are you requesting and why? How will your application/system/technology be implemented? Discuss your timeline and what will ensure this deployment will be successful. (max 1000 words)
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Where are patient healthcare records currently being stored? (max 250 words)
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How will you build clinician support for the adoption and use of the technology within your organization? What is the current sentiment of your clinicians about digital health tools? (max 1000 words)
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Please describe a timeline of your project. Please include milestones with start and completion dates to ensure an effective deployment plan.
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Initial planning phase, development phase with the Frontida Team, testing and deployment phase, maintenance phase.
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Will your staff be able to complete quarterly reports to Frontida and participate in quarterly check-ins to share successes and challenges with the system?
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Yes
No
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add "Other"
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Section 3 of 3
Contact Information
First Name
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Last Name
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Email Address
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Position/title at your organization
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Organization Name
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Organization Status and Tax ID
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Website (URL)
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Annual Operating Budget
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Organization Operational Location
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Are you an organisation or person on the the OFAC List of Specially Designated Nationals and Blocked Persons?
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Check the boxes that apply: Does your organization have access to
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Annual Number of Patients Served (on average)
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Does you organization serve patients in rural, developing, underserved, or low-resource communities?
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No responses yet for this question.
What type(s) of health care does your organization provide? (emergency, paediatric, primary care etc.)
No responses yet for this question.
What languages would your system need to be in? You can list multiple lanuages.
No responses yet for this question.
What type of health providers need access to the electronic health record system? Please select from the following list:
Copy
No responses yet for this question.
If other, please explain:
No responses yet for this question.
What is the current method being used to collect the health records of patients?
Copy
No responses yet for this question.
How many health providers would need access to your applications/system?  (How many user account would you need?)
Copy
No responses yet for this question.
Please explain how much funding your organization needs to use Frontida's applications? (i.e. My organisation can only pay $X yearly for Frontida's services. We need funding to pay for software development, licensing fees, training, etc.)
No responses yet for this question.
Copy
No responses yet for this question.
Goals and Aims
Why are you interested in being a part of the Frontida Fellowship?
No responses yet for this question.
Provide an overview of the region you operate in, your clinic, clinicians, and the population you currently serve. What amount are you requesting and why? How will your application/system/technology be implemented? Discuss your timeline and what will ensure this deployment will be successful. (max 1000 words)
No responses yet for this question.
Where are patient healthcare records currently being stored? (max 250 words)
No responses yet for this question.
How will you build clinician support for the adoption and use of the technology within your organization? What is the current sentiment of your clinicians about digital health tools? (max 1000 words)
No responses yet for this question.
Please describe a timeline of your project. Please include milestones with start and completion dates to ensure an effective deployment plan.
No responses yet for this question.
Will your staff be able to complete quarterly reports to Frontida and participate in quarterly check-ins to share successes and challenges with the system?
Copy
No responses yet for this question.
Contact Information
First Name
Copy
No responses yet for this question.
Last Name
Copy
No responses yet for this question.
Email Address
Copy
No responses yet for this question.
Position/title at your organization
Copy
No responses yet for this question.
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