Full Support Service Engagement Request

Shared Health’s Patient, Public and Family Engagement Team will provide support for recruitment, readiness, volunteer management, ongoing support and follow-up/evaluation of Patient and Family Advisors and your engagement activity including:

Finding Patient and Family Advisors;
Posting and sharing your engagement activity;
Receiving ongoing support from the Patient, Public and Family Engagement Team regarding your Patient and Family Advisors and your engagement activity; and
Developing skills helpful for patient engagement

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 7 - Contact Information

14%

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 will liaise with the Patient and Family Advisors.

First Last

Position

Phone

THE PROJECT

Project Name

Project Overview

Please use plain language to describe the project, the project’s purpose/goals and the relevance to potential patient and family advisors. Feel free to include background materials relevant to the project (e.g. Terms of Reference).

Terms of Reference / Document Upload

(optional)

Accepted file types: doc, docx, rtf, txt, Max. file size: 5 MB.

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)?

ENGAGEMENT STRATEGY

Level of engagement that you are considering for your activity?

(see definitions to the right)

Involve

Consult

Collaborate

Empower

Involve = Work with Patient and Family Advisors throughout a process to ensure their perspectives are understood, considered and reflected in recommendations. Their feedback influences the objective but the final decision/outcome is determined by the staff. Staff will provide feedback on how their input affected the decision.
Consult = Obtain feedback on decisions, materials and/or services. Staff will listen to and acknowledge their ideas and concerns, and provide feedback on how their input affected the decision. Patient and Family Advisors have no further involvement in the initiative, design or outcome.
Collaborate = Partner with Patient and Family Advisors in all aspects of the project, including development, execution, and implementation of outcomes. Staff will look to them for advice in decision making, developing alternatives, and solutions and include their recommendations into the decision as much as possible.
Empower = Patient and Family Advisors will co-design and co-create with the group as an equal member. Staff will implement what the Patient and Family Advisors decide.

What type of involvement are you looking for from the Patient and Family Advisors?

Ongoing involvement (e.g. involved on a committee or council that is a permanent group which may or may not have fixed terms)

Long-term involvement (e.g. involved on a committee or working group related to a project with an end date of a year or more)

Short-term involvement (e.g. involved on a committee or working group related to a project with an end date under a year)

One-time involvement (e.g. participate in a focus group, consultation or an event/meeting to provide input or share stories)

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

(check all that apply)

Advisory Council

Focus Group / Consultation

Speaker / Presenter / Facilitator

Survey

Working Group / Committee

Workshop

Not sure

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?

(a minimum of 2 is recommended)

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

Other Place

Virtual Technology Requirements Needed

(check all that apply)

Computer

Microsoft Teams

Smart Phone

Tablet

Zoom

Other

Other Virtual Requirement

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

Do you have individuals in mind already who would be suitable for this engagement opportunity?

Yes

Would you or your team like to meet potential Advisors to learn more about each other before confirming their participation?

Yes

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 and thank Patient and Family Advisors for their participation
- Share how/ if the goals of the opportunity/project have been met; and
- Share how the contribution and participation of the Patient and Family Advisors has influenced the outcome

I agree

Your name

Note: If you have not yet consulted Shared Health’s Patient, Public and Family Engagement Team, a member of our team will contact you once this form is received to ensure you/your team is prepared to participate and engage Patient and Family Advisors in a meaningful manner.