Consent to be Contacted by the Media
We are asking you to share your personal experience with home care and hospice, whether you are a provider, direct care worker, or recipient of these important services. Filling out this form lets us know you are comfortable sharing your story and allows us to reach out to you when we receive media inquiries about lived experiences. Thank you for participating in this important effort.
Parent/Guardian Name
*
First Name
Last Name
Email
*
example@example.com
Location: City
*
City
Location: Zip Code
*
Postal/Zip Code
Phone Number
*
Please enter a valid phone number.
Weekly Authorized Hours of PDN
*
Weekly Hours UNSTAFFED
*
Current Situation (select all that apply)
*
Suffering access to care issues related to nursing shortage in home care
Child is hospitalized related to negative outcome from unstaffed nursing hours related to the nursing shortage in home care
Child is hospitalized but cannot go home because there is no access to care related to nursing shortage in home care
Child has suffered a negative outcome from unstaffed nursing hours related to the nursing shortage in home care
Other
Are you comfortable with video interview?
*
Yes
No
Are you comfortable with phone interview?
*
Yes
No
What day of the week is best for a potential interview?
*
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday
What time of day are best for a potential interview?
*
Morning
Afternoon
Evening
Have you participated in media interviews in the past
*
Yes
No
Other
Signature
*
Clear
Submit
Should be Empty: