(e.g. diabetes, congestive heart failure, asthma, depression, arthritis) Or you can submit this form from the Internet at www.peacehealth.org/diabetes …
Patient/Family Representative Face Sheet
Representative Name:_______________________
Sign-up Sheet Received Entered in Database Deleted from
Database:___________
Written materials sent out No longer
interested:_____________
Interview Sheet Completed
Appropriate for: Focus Group Telephone Input Product Review
Share Story Committee
Referred to:______________________________
Scheduled for Orientation:______________ Orientation
Completed:________________
If they have interest in team/group activities, please provide next
Training date
Scheduled for Training Date:_______________
NOTES:______________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
___________________________________________________________________
Participation Log:
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Patient/Family Representative Sign-up Form
Do you or someone in your family live with a chronic
illness such as
congestive heart failure or diabetes? Through the Pursuing Perfection
Project, efforts are underway throughout Whatcom County to demonstrate
that effective, quality care can be provided in communities using a
patient-centered model, and we are seeking Patient/Family Representatives
to help
For more information on the Pursuing Perfection Project visit
wwwpeacehealthorg/P2, email hwilson@peacehealthorg or call 360756-
6885
Yes, I would like to volunteer sharing my experiences and thoughts about
health care Please contact me so I may contribute my voice to the
Pursuing Perfection Project
Name:_____________________________________ Date:__________________
Phone Number:______________________ Best time to
call:___________________
Mailing Address: _______________________________________________________
City Zip
County you live in:____________________ May we contact you? Yes
Clinic you are treated at:
Family Health Associates North Cascade
Cardiology
Ferndale Family Medical Center
SJH Center for
Senior Health
SeaMar Community Health Center Other:___________________
Do you have Internet access from home? Yes No
Email address:___________________________________ May we contact you?
Yes
I am a patient with a chronic health condition
eg diabetes, congestive heart failure, asthma, depression,
arthritis
Please identify your condition if you are comfortable doing so: Yes
No
I am involved in the care of someone who has a chronic health condition
I dont have a chronic health condition
Please indicate the ways in which you would like to participate as a
Patient/Family Rep:
___ Phone Interview: Share your opinion and respond to survey questions
over the telephone
___ Focus Group: Provide feedback in a group format with other patients
___ Participate on Committees: Bring the patient/family perspective to
committee meetings
___ Review Products: Try out new websites and review informational
materials
___ Story Sharing: Share your health care experiences with care
providers and other patients
___ Assist supporting change for physician and specialist
offices
___ Assist supporting change for the Hospital
Please return this form to: Pursuing Perfection Project
800 E Chestnut, Suite 2A
Bellingham, WA 98225
Or you can submit this form from the Internet at
wwwpeacehealthorg/diabetes
SCREENING QUESTIONS FOR PATIENTS/FAMILY MEMBERS VOLUNTEERING FOR
PATIENT/FAMILY POOL
Why are you interested in being involved?
What experience have you had working in groups working toward solving a
problem?
Are there barriers such as transportation, timing of meetings, language or
illness that need to be accommodated to allow your participation?
Staff Recommendation/Action:
