Tumaini Haven Patient Assistance

Helping eligible prostate cancer patients access Abiraterone acetate.

Q0. Who is completing this form?

1. Program Introduction & Consent

Key Information:

Voluntary participation; does not replace doctor's care.
Data Controller: InsightsIQ Solutions, Nairobi.
Data stored securely (potentially outside Kenya) with safeguards.
Shared only with treating team and program staff.
You can withdraw at any time.

2. Patient Eligibility Screening

Confirmed diagnosis *

Prostate cancer Other / No

Required (Must be Prostate Cancer)

Is Abiraterone acetate prescribed? *

Yes No

Required

Treatment facility (hospital/clinic) *

Select facility

3. Patient Demographics

Patient Full Name (as on ID) *Required

National ID Number (7-9 digits) *Invalid ID length

Date of Birth (DD/MM/YYYY) *

Patient must be at least 30 years old

Patient Phone *Invalid format

Alt Phone

County *

Required

Physical Location *Required

4. Medical & Treatment Information

Date Abiraterone started (if known)

Other treatments received (Select all) *

Hold Ctrl/Cmd to select multiple

5. Socio-Economic Assessment

Health Cover Type *

Is Abiraterone available under SHA at facility?

Employment Status *

Monthly Household Income (KES) *

Est. Monthly Treatment Cost (KES) *

Travel Companion? *

Round-trip Transport Cost (KES) *

6. Support Request

What type of support are you requesting? *

Access to Abiraterone medicine Financial assistance Counselling and education Adherence support

7. Adherence Baseline

Has the patient started taking Abiraterone? *

8. Submitter Details

Your Full Name *Required

Your Phone *Required

Your Email *Required

Your Title/Role *Required

9. Documentation

Upload Prescription Copy * File required

Upload Diagnosis Letter (Optional)

10. Review & Confirm

FINAL CONFIRMATION *

I confirm that the information provided is accurate to the best of my knowledge. By submitting this form electronically, I agree this electronic consent has the same effect as a handwritten signature.

Application Received

Thank you for submitting your request.
Our team will review your information and contact you shortly.

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Program Eligibility

Based on the information provided, this patient does not meet the current criteria for the Tumaini Haven program (Prostate Cancer diagnosis & Abiraterone prescription required).