PCOR-EM Use Request Form

Thank you for your interest in the Patient-Centered Outcomes Research Engagement Measure (PCOR-EM), Version 1.0. Please complete this form before using the PCOR-EM. Your responses help the PCOR-EM team track how the tool is used, gather feedback, and share updates and revised versions as research continues.

The form asks about you and your organization, your project, how you plan to use the PCOR-EM, and who will complete it. It takes about 5 minutes to complete.

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1. Name (Required.)

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2. Title or role

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3. Organization (Required.)

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4. Email address (Required.)

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5. Phone number

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6. Brief description of the project (purpose, setting, and populations engaged)

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7. How do you plan to use the PCOR-EM? (Select all that apply) (Required.)

Assess engagement on a current or recent project

Assess engagement at more than one point in time

Research on engagement (e.g., comparing engagement approaches, testing engagement strategies, or advancing engagement methods and best practices)

Training or capacity building

Engagement outside of research (for example, program or policy development)

Other (please describe)

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8. Anticipated lenses of those completing the PCOR-EM (Select all that apply)

Researchers

Engagement facilitators or specialists

Project managers or coordinators

Patient or community partners serving in formal engagement roles

Other (please describe)

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9. Anticipated number of respondents

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10. Anticipated administration (Select all that apply)

Web-based survey

Paper survey

Other (please describe)

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11. Anticipated timeline for use (Required.)

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12. Would you be willing to share deidentified response data with the PCOR-EM team? (Required.)

Yes

Unsure

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13. Agreement (required) (Required.)

I agree to be contacted by the PCOR-EM team for feedback on my use of the tool and to receive updates, including revised versions of the PCOR-EM as research continues. I understand that the PCOR-EM 1.0 is an early version and agree to use the most current version available.

PCOR-EM Use Request Form

Question Title

* 1. Name (Required.)

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* 2. Title or role

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* 3. Organization (Required.)

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* 4. Email address (Required.)

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* 5. Phone number

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* 6. Brief description of the project (purpose, setting, and populations engaged)

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* 7. How do you plan to use the PCOR-EM? (Select all that apply) (Required.)

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* 8. Anticipated lenses of those completing the PCOR-EM (Select all that apply)

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* 9. Anticipated number of respondents

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* 10. Anticipated administration (Select all that apply)

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* 11. Anticipated timeline for use (Required.)

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* 12. Would you be willing to share deidentified response data with the PCOR-EM team? (Required.)

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* 13. Agreement (required) (Required.)

1. Name (Required.)

2. Title or role

3. Organization (Required.)

4. Email address (Required.)

5. Phone number

6. Brief description of the project (purpose, setting, and populations engaged)

7. How do you plan to use the PCOR-EM? (Select all that apply) (Required.)

8. Anticipated lenses of those completing the PCOR-EM (Select all that apply)

9. Anticipated number of respondents

10. Anticipated administration (Select all that apply)

11. Anticipated timeline for use (Required.)

12. Would you be willing to share deidentified response data with the PCOR-EM team? (Required.)

13. Agreement (required) (Required.)