Basic Support Service Engagement Request

Shared Health’s Patient, Public and Family Engagement Team will:

Post your engagement activity / project on the Patient and Family Advisor Network
Share it with our Patient and Family Advisors who will be directed to your organization

In return, we ask that you:

Follow best practices in engagement
Inform Shared Health’s Patient, Public and Family Engagement Staff upon completion of the engagement opportunity regarding the following items:
- Provide a summary of how many Patient and Family Advisors were recruited through the Network; and
- How their contribution and participation influenced the outcome

Note: When completing this form, please use plain language, keep as short as possible, define acronyms, and avoid medical terms.

To ensure your submission is accepted, please avoid using any special characters in the form below, such as: ! ‘ # $ % ^ & * ( ) ?, etc.

Step 1 of 5 – Contact Information

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CONTACT INFORMATION

Organization

Program / Department

Health Region

Name of Staff responsible for Request

First Last

Position

Phone

Alternate Name of Staff responsible for Request

If different from above, name and contact information of staff who Patient and Family Advisors should contact for more information and/or to express interest.

First Last

Position

Phone

ENGAGEMENT ACTIVITY

Is your engagement activity / project related to

Health Research

Health Service / System

For additional support related to patient/public engagement in research, contact the George & Fay Yee Centre for Healthcare Innovation: https://umanitoba.ca/centre-for-healthcare-innovation/.

Name of the Engagement Activity

Overview of the Engagement Activity

Please use plain language to describe the purpose of engaging Patient and Family Advisors (e.g. What can a Patient and Family Advisor offer this project?) and what is the role of the Patient and Family Advisor (e.g. What will the Patient and Family Advisor be asked to do)?

Please choose which role the Advisors will be required to perform / participate in.

(check all that apply)

Advisory Council

Co-Researcher

Focus Group / Consultation

Speaker / Presenter / Facilitator

Survey

Working Group / Committee

Workshop

Other

Other role

ELIGIBILITY & LOGISTICS

Who would you like to engage?

(check all that apply)

Family Members / Caregivers

Patients

Public

Are you looking for any specific experiences or backgrounds for your opportunity?

Yes

Specific experiences or backgrounds

Please list any specific experience / backgrounds you require (e.g. experience with a health care area / procedure / condition, gender, age, geography (area of the province and/or urban or rural), ethnicity, community groups, etc.).

If recruiting patients with a certain health condition or experience in a healthcare area / procedure, please indicate if their experience needs to be within a certain time frame.

within the last year

within the last 5 years

time frame is not relevant

other

Other time frame

How many Advisors would you like to engage in your opportunity?

Do you know the exact dates, times and duration that the Advisors are needed?

Yes

How frequently will they participate?

Please include date(s), time, duration and how often (e.g. monthly meetings on a specific date and time requiring 2 hours per month for a year).

Start Date

End Date

Time

Duration

Frequency

Are you able to provide supports to Advisors as needed?

(e.g. interpreter, amplification, transportation, technical supports, accessible meeting spaces, etc.)

Yes

Support specifics

Where will the opportunity take place?

(check all that apply)

In Person

Phone

Virtually

Other

In Person Location / Facility

In Person Address

Street Address City / Town Province Postal Code

Virtual Technology Requirements Needed

(check all that apply)

Computer

Microsoft Teams

Smart Phone

Tablet

Zoom

Other

Other Virtual Requirement

Other Format

Will there be an honorarium provided for their participation?

Honorarium / compensation refers to paying Advisors for their time, energy and expertise, and may be considered income by the Canada Revenue Agency and may affect any provincial or federal programs/benefits they may be receiving such as Employment Income Assistance (EIA) and Disability.

Yes

Honorarium specifics

Will out of pocket expenses such as parking, transportation and caregiver / child care costs be provided?

Yes

Not Applicable (e.g. meeting virtually)

Exact expenses

Deadline to Express Interest in the opportunity

DD dash MM dash YYYY

MORE INFORMATION

Please list any social media platforms and/or your website to direct potential Advisors for more information about the organization and/or opportunity.

Social media platforms

Facebook

Instagram

Twitter

Website

Facebook Handle

Instagram Handle

Twitter Handle

CONSENT

Do you consent to have this opportunity posted publicly on the Shared Health’s website?

Yes

Your opportunity will only be emailed to the Advisors registered on the Network.

Contact details shared

I agree to have my contact details shared with the Patient and Family Advisors who might have questions related to this opportunity

I agree

Using services

In return for using the services of Shared Health’s Patient and Family Advisor Network, I consent to inform Shared Health’s Patient, Public and Family Engagement Staff upon completion of the engagement opportunity regarding the following items:

– Provide a summary of how many Patient and Family Advisors were recruited through the Network; and
– How their contribution and participation influenced the outcome

I agree

Your name