Engagement Request Form

Step 1 of 4

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.

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Geographic region for your initiative:*
- Provincial
- Fraser - Vancouver Coastal
- Interior
- Northern
- Vancouver Island
Are you looking for patient partners from specific cities or facilities (hospitals, clinics, etc.)?
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:*
The initiative name should be the role of the patient partner, and the name of the opportunity (e.g. Member, Quality and Safety Council or Speaker, Quality Academy Patient Panel).
Attention-grabbing statement:*
Please draft a 2-3 sentence pitch that will draw attention to the opportunity, thinking of who the patient partner is, what the opportunity entails and why the patient partner would be interested. See our tutorial for more tips.

e.g: "Island Health is revamping its public website and needs volunteers to attend a one hour in-person session in Victoria to test drive the site. Help ensure the creation of a user-friendly and easy-to-navigate website!"
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?)

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Section 9) Closing the Loop
Closing the loop is considered a critical step in the engagement process. It is the action of:

1. Acknowledging the engagement completion and thanking all involved for their participation;

2. Sharing how/if the aim of the project has been met; and

3. Sharing how the contribution and participation of patient partners influenced the outcome.

While it may seem early, we ask that you give some thought to how you will ‘close the loop’ at the end of the engagement, or when a patient partner completes their term on a committee. We acknowledge that parts 2 and 3 may not be feasible for sometime after the event or meetings with patient partners have ended. Engagement Leaders are committed to working with you to ensure that information is captured and shared with patient partners when it becomes available.

To assist you in closing the loop, PVN has created a “Closing the Loop” online form. Submitting this form at the end of the engagement will be your final requirement as a health care partner with PVN. When feasible, we strongly encourage PP and HCP teams to complete this form together to reflect on their work, chat about lessons learned and celebrate successes. Engagement Leaders are available to assist with facilitating these conversations if required.
Do we have your commitment to Close the Loop?
- Yes
- No
When would be a good time to connect with you regarding closing the loop (estimated end date of engagement)?
Date Format: MM slash DD slash YYYY
Section 9) Consent
Do you consent to have this initiative posted on our website, which is publicly available?*
- 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.

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