Requests for WebEncounters

Request to Schedule WebEncounters

Please complete the information below.
Name of Organization *
Name of Person Scheduling WebEncounters *

First Name Last Name
Title of Person Scheduling WebEncounters *
Email of Person Scheduling WebEncounters *
example@example.com
Phone Number of Scheduling WebEncounters

Area Code Phone Number
Please select the topic(s) for your WebEncounter *

Organ family donation conversation Tissue family donation conversation Conducting a physician meeting (hospital development) DRAI
Reason(s) for training: *

Practice initiated by learner Skill sign off for orientation Skill assessment - annual or routine Focused skill improvement assigned by leadership
How many WebEncounter sessions do you anticipate needing? *
Please select the specific family donation conversation focus: (please check all that apply) ORGAN

Family Understands BD-Fundamental Dual Advocacy Family Understands BD-1st Person Authorization Family Understands BD-Fundamental Dual Advocacy/Pediatric Family Does Not Understand BD-Fundamental Dual Advocacy Decision Made to Modify/Reverse Full DNR Decision Made to Support through Brain Death Decision Made to WD Treatment DCD Family Mentions Donation-Positive About Donation Family Mentions Donation-Reopening Conversation Healthcare Team Mentions Donation - Reopening Conversation Healthcare Team Mentions Donation-Slow Down/Delay Conversation Pulmonary or Hemodynamic Instability-DNR Rapid Recovery Family Understands BD - Dual Advocacy Before BD or WD I prefer multiple areas of focus for different learners and would like to discuss N/A
Please select the specific family donation conversation focus: (please check all that apply) TISSUE

Building Relationships with Healthcare Team Building Relationships with Healthcare Team - 1st Person Authorization Unanticipated Call at Home Unanticipated Call at Home - 1st Person Authorization Explores Decline (Too Sick / No Cutting) - 1st Person Authorization Explores Decline (Doesn't Know Wishes) Explores Decline (Family Unaware) - 1st Person Authorization Intense Emotion and Anger Wants to Delay Decision-Making - 1st Person Authorization Building Relationships with Gatekeepers I prefer multiple areas of focus for different learners and would like to discuss N/A
Please select the preferred date range for the WebEncounters: *
Please select preferred time of day for the WebEncounter sessions:

0900 - 1200 1200 - 1500 1500 - 1900
What time zone is your staff located in? We need this in order to properly schedule the sessions. *
Is there any other information you feel is important for us to know?
Thank you for reaching out to Gift of Life Institute concerning the WebEncounter tool. Someone from the Institute will follow up with you by the end of the next business day.

Sincerely,

Theresa A. Daly

Director

Gift of Life Institute
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Request to Schedule WebEncounters