Website
Name
*
First Name
Last Name
Email
*
example@example.com
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Organization
*
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
What is your role in palliative care?
*
Which tool(s) are you requesting to use?
*
Palliative Performance Scale Version 2 (PPSv2)
Bereavement Risk Assessment Tool
Bowel Performance Scale
Respiratory Congestion Scale
Psychosocial Assessment Tool
10 Steps for Better Prognostication
Would you be using the tool(s) for profit?
*
Yes (add details below)
No
Please provide more information abut how you will use the tool(s)
*
Is the website public or internal?
*
Public
Internal
If known, please provide the link of the website:
If the website is available publicly, do you agree to use the sample version of the tool?
*
Yes
No
Not applicable
Back
Next
Please review and check each clause to confirm your agreement with the copyright permission terms:
*
Permission is granted for non-exclusive rights to publish the tool(s) in the requested language only.
A credit line will appear at the bottom of the tool(s) and will include Copyright Victoria Hospice Society, BC, Canada www.victoriahospice.org.
No modifications to the content, structure and meaning of the tool(s) is allowed.
The tool(s) must be used with complete usage instructions, including the chart, instructions for use and definition of terms.
The tool(s) must not be used in any way that generates profit from the tool(s) itself, including resale, licensing, or commercial distribution.
If the website is published and open-access, the sample version of the tool(s) must be used.
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