PPIC Demographic and Contact Information

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* 1. Please provide us with your contact information

First Name

Last Name

Address

City/Town

State/Province

ZIP/Postal Code

Country

Email Address

Phone Number

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* 2. Prefered name or nickname

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* 3. Education Credentials

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* 4. Month of Birth

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* 5. Day of Birth

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* 6. Age Range

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* 7. Gender

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* 8. Race/Ethnicity

White or Caucasian

Black or African American

Hispanic or Latino

Asian or Asian American

American Indian or Alaska Native

Native Hawaiian or other Pacific Islander

Other (please specify)

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* 9. Please provide your primary and other healthcare affiliations. These are organizations where you are a volunteer, consultant or employee.

Primary Affiliation

Additional Affiliation

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* 10. What classification best describes your role in healthcare? Check all that apply

Professional: Clinician

Professional: Non-Clinical

Professional: Patient and Family Engagement

Patient and Family Advisor

Healthcare Consultant

Patient

Caregiver

Other (please specify)

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* 11. Do you have personal experience, as a patient, family member or care giver in any of the following Hospital Acquired Conditions? Please check all that apply.

Adverse Drug Event (ADE)

Catheter-associated urinary tract infections (CAUTI)

Central line-associated blood stream infections (CLABSI)

Injuries from falls and immobility

Obstetrical adverse events

Pressure Ulcers

Surgical site infections

Venous thromboembolism (VTE)

Ventilator-Associated Events (VAE)

Readmissions (within 30 days for the same diagnosis

Diagnostic Error

Other

Other (please specify)

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* 12. Do you have a healthcare story that you would be willing to share with different audiences? These stories will be explored more in follow up contact.

PPIC Demographic and Contact Information

Question Title

* 1. Please provide us with your contact information

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* 2. Prefered name or nickname

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* 3. Education Credentials

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* 4. Month of Birth

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* 5. Day of Birth

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* 6. Age Range

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* 7. Gender

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* 8. Race/Ethnicity

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* 9. Please provide your primary and other healthcare affiliations. These are organizations where you are a volunteer, consultant or employee.

Question Title

* 10. What classification best describes your role in healthcare? Check all that apply

Question Title

* 11. Do you have personal experience, as a patient, family member or care giver in any of the following Hospital Acquired Conditions? Please check all that apply.

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* 12. Do you have a healthcare story that you would be willing to share with different audiences? These stories will be explored more in follow up contact.

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* 13. Do you have other experience or a career in the healthcare field?

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* 14. Have you had previous Speaking Experience?

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* 15. Can you provide me with a bio and headshot?

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* 16. Share your story here!