IPE Patient/ Family/ Caregiver Partner Form

Dear Partner,

Thank you for your interest in becoming an Interprofessional Education (IPE) Patient/ Family/ Caregiver Partner at the Centre for Advancing Collaborative Healthcare & Education (CACHE), as part of the University of Toronto's IPE Curriculum. We welcome all individuals from various communities, abilities and identities to engage in this volunteer opportunity with the University of Toronto.

Should you have any questions about the form, please contact:

Elizabeth Cadavid
Education Coordinator; IPE Patient Partner Advisory Committee Co-Chair
eli.cadavid@uhn.ca

IPE Patient/ Family/ Caregiver Partner Criteria
Opportunity Requirements:

Complete this volunteer form;
Be available for a brief phone interview to discuss your application, if more information is needed;
Attend educational and orientation opportunities;
Be willing to share experience as a patient/client/family member and/or caregiver;
Be supportive of teamwork across professions with a nonjudgmental and accepting attitude to learners and positive key messages to learn from.

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* 1. Partner Information

Name

City

Province/State

Phone Number

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* 2. Are you a (please check):

Patient/Client that received or are currently receiving care

Family member or caregiver of a patient/client

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* 3. Please tell us a little about yourself or that of the person you are caring for: the chronic health condition, and the health care experience.

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* 4. Please tell us (if applicable) a little about any of your patient/family/caregiver partner activities.

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* 5. Do you have any exposure and/or experience with an interprofessional team of health professionals?

Interprofessional teamwork refers to the cooperation, coordination, and collaboration expected among members of different professions in delivering patient-centered care collectively.
An example of interprofessional collaboration would be a doctor, nurse, physical therapist, occupational therapist, and pharmacist working together to carry out an individualized plan of care in order to improve a patient's health status.

Yes

Please share more detail if applicable.

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* 6. What opportunities are you interested in? Select all that apply.

Sharing your story/ lived experience i.e. be interviewed by an interprofessional student group

Serve on an IPE Curriculum working group or committee (Bring the patient/client/family perspective)

Facilitate an IPE Learning Activity

Are there any other areas of interests you have that are not listed above - we welcome all comments for consideration

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* 7. Is there anything else you would like us to know?

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* 8. Do you grant to the Centre of Advancing Collaborative Healthcare & Education, University of Toronto, the right to take, use, exhibit, display, distribute and create derivative works of the photographed/filmed images of yourself, taken at any IPE related events/meetings, for use in connection with the activities of the Centre/University or for promoting, publicizing or explaining the Centre/University or its activities?

Yes

Not at this time but can consider for future, specific events/meetings

Please share more detail if applicable.

Thank you so much for expressing interest in becoming an IPE Patient/ Family/ Caregiver Partner with the University of Toronto's IPE Curriculum!
You will be contacted to schedule a one-on-one meeting. The meeting will further explore your health care experience(s) and interests.

Should you have any questions please contact:

Elizabeth Cadavid
Education Coordinator; IPE Patient Partner Advisory Committee Co-Chair
eli.cadavid@uhn.ca