Promoting Excellence : Patient Enrollment Form

Name:
Children's Hospital: Patient Enrollment Form

Definition:
This form identifies or screens patients for an end-of-life care program.

Category:
Organizational Tools - Enrollment Criteria/Patient Identification

Source:
Children's Hospital and Regional Medical Center
Pediatric Palliative Care Project
Mail Stop CM - 11
4800 Sand Point Way, N.E.
Seattle, WA 98105
www.cshcn.org

Contact:
Beth McKinstry
bmckin@chmc.org

How the grantee used this instrument:
Self-administered by parent or guardian with in-person assistance from Consultant at the pre-enrollment home visit.

Keywords:
pediatric, appropriate patients, identifying patients, patient criteria, patient screening, patient selection

To use this tool:
You may print and copy this tool for your own use from this site. Please credit source.

References:
Developed specifically for this project by the project team.

To view this tool:
Left click on the download link to view the PDF document in your Web browser. Right-click on the download link to save the document to your computer.
PDF 160 KB / 2 pages (Viewing PDF files requires downloading and installation of the free Adobe Acrobat Reader.)

Posted September 2003

Children's Hospital and Regional Medical Center overview page