Community Partnership Group
Membership Application

The Ministry of Health and Long-Term Care (MOHLTC) has recently invested in a new Prenatal Screening Program for Ontario, which will be managed by BORN (Better Outcomes Registry and Network) Ontario.

The Prenatal Screening Program (PSP) is seeking advice from the prenatal screening community, including both healthcare professionals as well as members of the public. While BORN begins building the Prenatal Screening Program, we are seeking advice from the public on educational material, quality assurance of the program, standards of care, and revised screening options that could be integrated in the current prenatal screening program.

The Prenatal Screening Program is creating a Community Partnership Group to understand the needs of the community and their experiences as it relates to prenatal screening.

If you have been pregnant, or were the partner or family member of a pregnant patient, in the last two years, received care in Ontario and are interested in participating in the Community Partnership Group, please complete the information below.

If you have any questions about this process or about the Prenatal Screening Program, please contact us at (613) 737-2281 or toll free 1-833-351-6490.

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* 1. Personal details

First Name

Last Name

Address

City

Postal Code

Phone (daytime)

Phone (evening)

Fax

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* 2. How do you prefer to be contacted? (please check all that apply)

Phone (daytime)

Phone (evening)

Fax

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* 3. What is your experience with prenatal screening? (please check all that apply)

Patient

Pregnancy with Down syndrome

Prenatal screening result - low risk

Screening declined

Perinatal loss (miscarriage, stillbirth, neonatal death, termination)

Prenatal care with Obstetrician

Partner/Family member of patient

Baby with Down syndrome

Prenatal screening result - high risk

Consulted genetic services regarding screening results

Prenatal care with Midwife

Prenatal care with Family Physician

Other (please specify)

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* 4. Please tell us about yourself and your experience with prenatal screening.

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* 5. Please describe why you want to become a member of the Community Partnership Group.

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* 6. What do you think are the most important topics that should be addressed by this group?

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* 7. Please indicate if you are also interested in participating in one of the prenatal screening operations task forces (please check all that apply).

Data and Quality Assurance: Provides guidance to the PSP on strategies for assuring quailty of data, improving performance of prenatal screening, of collection data and use of data.

Education: Provides support and assists with the development of the PSP Education Strategies, this will include guidelines for the PSP website, decision aids, education tools, etc.

Clinical Standards: Provides guidance regarding clinical issues related to prenatal screening. This will include evaluation of current practice in prenatal screening and recommend changes to improve consistency and quality of prenatal screening services.

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* 8. What times would be convenient for you to attend meetings? (please check all that apply)

	Time
Monday	Monday Time menu
Tuesday	Tuesday Time menu
Wednesday	Wednesday Time menu
Thursday	Thursday Time menu
Friday	Friday Time menu

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* 9. DO YOU HAVE OTHER COMMENTS THAT YOU WISH TO SHARE WITH US?

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* 10. If you are not chosen as a member of the Community Partnership Group, would you consent to being contacted by email for specific questions regarding prenatal screening or be willing to be part of a pilot study group to review educational/web-based materials?

Yes

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* 11. Would you be interested in Chairing/Co-Chairing this group?

Yes

Unsure