Engagement Request Form

Section 3) Engagement Strategy

We use the International Association of Public Participation (IAP2) Spectrum of Engagement to help our health care partners and patient partners to set expectations for involvement with set language for goals and promises.

Please check the level of engagement that best fits your initiative:*

This opportunity is at the level of inform on the spectrum of engagement (www.iap2.org). The promise to you is that the health care partner will provide you with clear and objective information.
This opportunity is at the level of consult on the spectrum of engagement (www.iap2.org). The promise to you is that the health care partner will listen to and acknowledge your ideas and concerns, and provide feedback on how your input affected the decision.
This opportunity is at the level of involve on the spectrum of engagement (www.iap2.org). The promise to you is that the health care partner will work with you to ensure that your ideas and concerns are reflected in recommendations and provide feedback on how your input affected the decision.
This opportunity is at the level of collaborate (at a local community or program level) on the spectrum of engagement (www.iap2.org). The promise to you is that the health care partner will look to you for advice in decision making, developing alternatives, and solutions and include your recommendations into the decision as much as possible.
This opportunity is at the level of empower (at a local community or program level) on the spectrum of engagement (www.iap2.org). The promise to you is that the health care partner will implement what you decide.

Section 4) Eligibility & Logistics

Please detail the following:

Eligibility criteria:*

List any skills/experiences/identifiers that are required or would be an asset (i.e. experience with specific part of the health system, skills, expertise, age, gender, connection to specific communities, etc.).

For example:
- Experience working in large groups
- Comfort telling their story
- Some familiarity with data analysis
- Etc.

Number of vacancies (a minimum of two patient partners is recommended):*

Location, Date, Time and Frequency (please describe to the best of your ability at this time):*

Please include the first meeting date and time.

Initiative Format:*

Please check the technique that you are considering:

Connection Method:*

In-Person
Teleconference
Webinar
Other

If you chose "Other", please specify below:*

Commitment (how long do you need a patient partner to be involved?):*

One time
One week to six months
Seven months to a year
Over a year

Section 5) Reimbursement

There is an expectation that health care partners cover related expenses. Pre-payment and/or expedited reimbursement for out of pocket expenses may be required.

Please list the expenses you are able to cover and estimate reimbursement timeline. Note any limitations or restrictions:*

Section 6) Background

Expanding as you can on the short aim statements you identified above, please provide relevant history and background information for your initiative, including:*

• Why has this opportunity come about?
• Who else will be involved?
• Are there any potential risks, and how might they be mitigated?
• Any background materials relevant to the initiative (e.g. Terms of Reference)
• What care setting is this most directly related to? (e.g. Acute Care, Community Care, Residential Care)

Would you like to attach any documents like ToR or other materials?

Section 7) RSVP

Are there particular questions that you would like to ask patient partners to help you select the appropriate people for your initiative?*

(e.g. why are you interested, do you have experience with xx health department/organization, please describe your skills and education such as data analysis, public speaking, etc.)

Section 8) Communication Plan

Frequent and fulsome communication with patient partners is a key success factor in patient engagement. In addition to ensuring there is one primary contact person available to support patient partners, giving ample notice when scheduling meetings and ensuring that materials and meeting requests are circulated in a way that is compatible with the patient partner’s computer systems and preferences, it is important to provide frequent updates and feedback on how patient partner input is making a difference. This is particularly important for long-term engagements where months may pass between meetings.

Please describe how you will keep patient partner(s) updated on the project progress and the impact of their participation throughout the project.

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