Staff Champion Report Form

Working together with an adviser can help St. Jude meet the needs of patients and families. Completing this report form will assist you in reviewing adviser involvement. Patient Family-Centered Care staff appreciates your feedback!

Asterisk (*) indicates a required field.

Contact Information

First Name*

Last Name*

Phone Number*

Email Address*

Adviser Information

Check all that apply*

Adviser(s) attended in person Adviser(s) attended by phone Contacted the adviser prior to the meeting to share meeting agenda, meeting details, and other documents Checked that the adviser understood the meeting date, time, and location Introduced the adviser and explained their role Gave the adviser the opportunity to provide feedback throughout the event Answered adviser's questions Called or talked with the adviser after the meeting to debrief

Answer these questions to best reflect your perspective:

Please provide us with a brief summary of the adviser's involvement and any additional comments, questions or concerns you may have.

Would you like Patient Family-Centered Care staff to contact you to follow up on any of the information provided above?*

Yes, I would like PFCC staff to contact me No, I do not need PFCC staff to contact me

I agree to share this information with St. Jude*
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