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Partnership Survey

Please complete the survey below.

Thank you!

Thank you for your interest in the Family Partnerships Program at Boston Children's Hospital. We appreciate your willingness to give back to the Boston Children's community.

Boston Children's offers many different ways for patients and families to give back - from engaging in fundraising events, to cooking meals for patients and families staying in our off-campus housing, to serving on project committees. Before completing our Family Partnerships Interest survey, please review our guide, "Ways to 'Give Back' to Boston Children's Hospital," which outlines engagement opportunities in more detail. If you're interested in an opportunity not listed in this guide, please contact us at FamilyPartnerships@childrens.harvard.edu.

The survey below helps us to learn more about you so we can match you with opportunities that best meet your interests and availability. We appreciate your time and look forward to connecting with you.

Attachment:Ways_to_Give_Back_to_Boston_Childrens_Hospital.pdf

First Name

* must provide value

Last Name

* must provide value

Are you a Boston Children's Hospital:

* must provide value

Patient

Parent

Grandparent

Guardian

Sibling

Other

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If Other, please specify:

Street Address

* must provide value

City

* must provide value

State

If you live outside of the United States, please choose "MA" for the state and provide the name of the country you live in in the next question.

* must provide value

COUNTRY

Zipcode

* must provide value

Home Phone Number

Cell Phone

Email Address

What Boston Children's Hospital locations do you or your child(ren) receive care at?

Emergency Department

Inpatient Units (overnight stays)

Outpatient Units (clinic visits)

Primary Care

Martha Elliot Health Center

Satellite Clinics

Boston Children's Hospital Physician Office locations

If you or your child(ren) receive care at Boston Children's satellite locations, please mark the locations that you have visited/receive care at:

Lexington

Peabody

Waltham

If you or your child(ren) receive care at a Boston Children's Physician Office location, please mark the location(s) that you have visited/receive care at:

Brockton

Milford

North Dartmouth

Norwood

Weymouth

Please specify the inpatient unit(s), specialist(s) and/or satellite(s) where you/your child are seen.

* must provide value

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Please mark all of the clinics and/or departments where you or your child are, or have been, cared for:

Adolescent Medicine

Allergy and Immunology

Brain Center

Cancer and Blood Disorders Center

Cardiology

Critical Care Medicine

Dentistry

Developmental Medicine

Emergency Department (ER)

Endocrinology

Gastroenterology, Hepatology

General Surgery

Genetics and Genomics

Gynecology

Heart Center

Infectious Diseases

Nephrology

Neurology

Neurosurgery

Newborn Medicine

Nutrition

Ophthalmology

Orthopedic Center

Otolaryngology and Communication Enhancement

Pediatric Transplant Center

Plastic and Oral Surgery

Primary Care

Psychiatry

Pulmonary and Respiratory Diseases

Rheumatology

Sports Medicine

If you or your child has had one or more inpatient stays at Boston Children's Hospital, please indicate the floor(s)/unit(s) where you stayed:

6NorthEast: Hematology, Oncology

6West: Stem Cell Transplant

7North: Neonatal ICU

7South: Medical/Surgical ICU

7West: General Medicine

8East: Cardiology/Cardiac Surgery

8South: Cardiac ICU

9NorthWest: Neuroscience

9East: General Medicine

9South: General Medicine

10East: Infant/Toddler Surgery

10South: Surgical/Solid Organ Transplant

10NorthWest: Surgical/Orthopedics

11South MICU: Medical ICU

11S ICP: Intermediate Care (Step Down)

Bader 5: Inpatient Psychiatry

Waltham 3W: Surgical

Waltham ICBAT: Waltham Psychiatry

If not listed above, please share any other clinics or inpatient units where you or your child receive(d) care.

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After reviewing the "Ways to Give Back to Boston Children's Hospital" guide, please mark the areas that you are interested in participating in:

Become a Family Partner:

Email surveys: At home, online, typically less than one-hour commitment per survey.

Focus Groups: In person or by phone, usually one-two hour commitment, may be one-time or a series of a few meetings.

Committees/Workgroups: Time commitment varies by project. Typically requires some in-person volunteer hours.

Virtual Advisory Council: Time commitment is extremely flexible. Constructive feedback provided for timely and relevant projects through a secure online forum.

Family Advisory Council: Time commitment is 2.5 hours every month for Council meetings (in-person attendance is preferable) plus approximately 1-3 additional volunteer hours per month for committee/workgroup participation. New members are added once or twice per year.

Family-to-Family Mentor: Available for certain departments/diagnoses. Includes one-time 4-hour training and 1-2 brief conversations with mentees on an as needed basis.

Teen Advisory Committee: Patients/siblings group. Members may join during freshman or sophomore year in high school. Minimum commitment is one full school year of monthly meetings (11 meetings)

Latino family engagement: contact Cecilia Matos at (617) 355-3196 or cecilia.matos@childrens.harvard.edu

Volunteer Services Program: Visit the Volunteer Services webpage at: www.childrenshospital.org/ways-to-help/volunteerservices

Cook a meal for families: contact FamilyHousing@childrens.harvard.edu

Get involved with the Boston Children's Hospital Trust: See Ways to Give Back to Boston Children's Hospital guide for contact information

Tell your story: Email marketing at marketing@childrens.harvard.edu

Join the Child Advocacy Network (CAN): contact Government Relations at kathryn.audette@childrens.harvard.edu or (617) 919 3062

Other

Please share with us some information about why you would like to get involved with Family Partnerships.

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If Other, please specify:

Area(s) of Interest

Building and Facilities

Clinical Education and Training (Bringing the patient/family perspective to Boston Children's Hospital employees)

Family Education (Improving written or video-based education about a wide variety of topics to patients and families)

Patient and Family Experience (May be inpatient or outpatient)

Hospital Policies and Processes

Research

Technology (How clinicians / the hospital use technology to connect with patients and families)

International Patient and Family Experience

Other

If Other, please specify:

Profession / Industry

Do you speak any languages in addition to English?

Yes

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If 'yes' please list the languages you speak

Skill(s)

Marketing

Public Speaking

Reviewing/Editing Materials

Strategic Planning

Technology

Writing

Other

If Other, please specify:

Please share some of your hobbies and interests outside of your profession. (This helps us to know you better)

Expand

Does your schedule allow you to:

Attend meetings in person during regular business hours? (Mon-Fri 8:30am - 5pm)

Attend meetings in the evening? (5:30pm or later)

Participate in meetings, conference calls, interviews over the phone during regular business hours?

Participate in providing feedback online (Through our Virtual Advisory Council)

Complete surveys online

If you are able to attend meetings during business hours, how often are you able to do so?

Regularly (weekly or bi-weekly)

Once in a while (once a month or less)

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If you are able to attend meetings in the evening (5:30pm or later), how often can you do so?

Regularly (weekly or bi-weekly)

Once in a while (once a month or less)

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