Requests for WebEncounters

Request to Schedule WebEncounters

Please complete the information below.
Currently, Gift of Life Institute is seeing an increase in requests for WebEncounter sessions and we are doing our utmost to meet your needs. As always, our goal is to confirm sessions during your requested time blocks and ask for your consideration and patience during this busy time if adjustments are needed.

Please note that WebEncounters will not be scheduled until Tuesday, January 16, 2023.

We will respond to all requested received between December 9, 2023- January 5, 2024, no later than January 9, 2024.

Thank you for your continued support and patience.
Name of Organization*
Name of Person Scheduling WebEncounters*

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

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

Organ family donation conversationTissue family donation conversationConducting a physician meeting (hospital development)DRAI
Reason(s) for training:*

Practice initiated by learnerSkill sign off for orientationSkill assessment - annual or routineFocused skill improvement assigned by leadershipOther
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 AdvocacyFamily Understands BD-1st Person AuthorizationFamily Understands BD-Fundamental Dual Advocacy/PediatricFamily Does Not Understand BD-Fundamental Dual AdvocacyDecision Made to Modify/Reverse Full DNRDecision Made to Support through Brain DeathDecision Made to WD Treatment DCDFamily Mentions Donation-Positive About DonationFamily Mentions Donation-Reopening ConversationHealthcare Team Mentions Donation - Reopening ConversationHealthcare Team Mentions Donation-Slow Down/Delay ConversationPulmonary or Hemodynamic Instability-DNRRapid RecoveryFamily Understands BD - Dual Advocacy Before BD or WDI prefer multiple areas of focus for different learners and would like to discussN/A
Please select the specific family donation conversation focus: (please check all that apply) TISSUE

Building Relationships with Healthcare TeamBuilding Relationships with Healthcare Team - 1st Person AuthorizationUnanticipated Call at HomeUnanticipated Call at Home - 1st Person AuthorizationExplores Decline (Too Sick / No Cutting) - DMVExplores Decline (Doesn't Know Wishes)Explores Decline (Family Unaware) - 1st Person AuthorizationIntense Emotion and AngerWants to Delay Decision-Making - 1st Person AuthorizationBuilding Relationships with GatekeepersI prefer multiple areas of focus for different learners and would like to discussN/A
Please select the preferred date range for the WebEncounters:*
Please select preferred time of day for the WebEncounter sessions:

0900 - 12001200 - 15001500 - 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