Passy-Muir Centers of Excellence

Thank you for your participation in the Passy Muir Centers of Excellence program. Please provide the following information and supporting items to showcase your facility.

1. Name of Facility

2. Facility Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry

3. Website

4. Contact Information of Clinical Representative

5. Phone Number

Area CodePhone Number

6. E-mail

7. 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)

0/250

8. Team Photo including names, credentials, and titles of persons pictured

Please upload the following documents (required):

9. Team Photo including names, credentials, and titles of persons pictured

10. Consents for every person used in any uploaded media - download form here, then scan to PDF or graphic file

11. Facility Passy Muir Valve policy and procedure (including in-line application if ventilator patients)

12. Videos (patient testimonials, Passy Muir Valve placements, clinician testimonial-due to large file sizes, videos are uploaded separately to Hightail)

Additional items (not required but recommended):

13. Documentation of measurable outcomes that support excellence of program (e.g. weaning outcomes, oral feeding/swallowing measures, etc.)

14. Photos of patients using the valve

15. Success story descriptions (supported by pictures, videos)

16. Publications regarding the Passy Muir Valve and/or care of trach and vent patients

17. Presentations regarding the Passy Muir Valve and/or care of trach and vent patients (past or future)

18. Other items you feel support your excellence

Upload multiple files using this button:

Upload Files

I, the undersigned, hereby consent to the use by Passy Muir, Inc., of the name,
likeness, statements, quotations, images, photographs, and/or video of the above-mentioned facility in the Passy Muir Centers of Excellence program.

Please type name to consent to the statement above

Click "Submit Form" to complete the process.