Family/Friend Caregiver Nomination for UTP Project -- Submit this form once for each nomination
PLEASE DO NOT HIT THE BACK BUTTON ON YOUR BROWSER UNTIL YOU PRESS SUBMIT AT THE BOTTOM OF THIS FORM

CRITERIA for nomination:
o Family/Friend caregiver is closely involved with patient’s care
o Family/Friend caregiver’s patient has gone through one or more transfers from one site to another
o Family/Friend caregiver’s patient has a complex health history
o Family caregiver is English speaking

NOTE: You are free to nominate caregivers without nominating their patients, and vice versa.

For people you nominate, please contact them to inform them that we will be calling to:

o Talk about this state-wide project to improve the accuracy and timeliness of the health information their providers receive.

o Arrange a time to have a conversation to ask their opinion about the kind of information they believe is important for care providers to know about their health status when their care is transferred from one place to another (e.g. clinic to hospital; hospital to home health agency).

o Inform them that this will be completely confidential.
Your Name *
Your Email *
Your Cell Phone
Fill in if you use (and like) texting communications
Family/Friend Caregiver Nomination
To suggest someone for the UTP Project to interview who is a Family or Friend Caregiver of a LTSS patient
Caregiver Name *
Best way to contact *
Phone number and/or email address
Reason you believe this person would make a good participant
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