Engagement Request Form

By reviewing and completing this form, you are preparing to engage patient partners in your improvement work.

For examples of language used in similar opportunities, and to see how we work with the information you provide, please look at our current opportunity listings. We’ve put together a checklist of questions you may want to ask yourself before moving forward with engaging patient partners in an initiative to ensure that they are prepared and supported to participate in a meaningful manner.

As you work through the form, you are able to save your work creating a unique link that you and your colleagues can access from any computer.

After submitting the completed form, you will get a copy of it in your email and an engagement leader will connect with you to discuss your initiative and next steps. And if you have any questions about the engagement request forms, this list of frequently asked questions may be helpful.

If you encounter any technical difficulties or have any question about the form, please connect with the Engagement Leader in your region.

Geographic region for your initiative:*

Section 1) Contact Information

Key contact:*

Email*

Phone*

Organization & Department:*

Social Media:

Please provide your social media handles and suggested hashtags, so that we can tag you and/or your organization in posts about the opportunity.

Secondary contact:

Email

Phone

Section 2) Initiative

Initiative name:*

If you do not have a name for your initiative, please provide a brief, high level description.

Attention grabbing statement:*

Please draft a 1-2 sentence pitch explaining the initiative

e.g: "Do you have an interest in helping to improve the quality of Home Support Service delivery as part of an ongoing advisory committee?"

Geographic region of the opportunity:*

Do you have any specific geographic requirements?

e.g: "For volunteers in and around the area of XX City/Hospital"

Aim*

Short plain language statement explaining your initiative. Please consider:

• What is the aim or goal of your initiative? (Why are you doing this?)
• What is the purpose of engaging patient partners in this work? (What can a patient partner offer this initiative?)
• What is the role of the patient partner? (What will the patient partner be asked to do?)

Initiative Format*

Please check the technique that you are considering:

Survey / Polling
Focus Group
Workshop
Conference
Working Group
Advisory Committee
Patient Speaker
Other

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

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) 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):*

Format:*

In-Person
Tcon
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) Closing the Loop

When this placement concludes, how might you share updates or outcomes with the patient partners?*

Closing the Loop is a required step within the PVN process. While we understand you may not have all the information at this time, please provide some initial thoughts about what information you may be able to provide to patient partners, when and how this information might be available.

e.g.: results patient partners can expect, completion date, and how the information will be shared with them, such as via telephone or email.

Section 9) Consent

Do you Consent to have this initiative posted on our website, which is publically viewable?*

Yes
No

Do you Consent for us to share your contact details with PVN Patient Partners and/or other health care partners who might have questions related to this initiative?*

Yes
No

Section 10) Feedback

We would appreciate your feedback about our process and this form. Any comments or suggestions are welcomed.

More Information