Patient Education Request Intake

Welcome to Patient Education Advisory Council (PEAC) Submission Page

Thank you for partnering with us on your patient education request. At Dartmouth Health, we aim to make patient education user friendly for patients and providers.

This means we'll work with you during this process to make sure education for our patients is evidence-based, in plain language, clear and accessible.

Before you fill out this form

Check for Existing Patient Education

Check the Healthwise Patient Education library to see if materials exist to meet your needs. You can access the library here. If you find suitable materials, we would be glad to know what you found and if we can be of any further assistance.

If you have any questions or need assistance, please contact us at PatientEducation@hitchcock.org

Your Contact Information

Your Full Name*

Please note: As the submitter of this project, you will be contacted to give feedback and will receive notifications when your project is moved to the next step in the process--if you are not the appropriate person to receive these communications, please add the appropriate contact's name.

Department

Select

If "other" department, please add here

Your Phone Number

Phone

Your Email*

Please choose which site/location you are submitting from

Select or enter value

If other, please write in the site/location you are submitting from

Practice/Unit/Nurse Manager Email*

Please note: Your listed manager/leader will receive a message letting them know that this project has been submitted.

Tell Us About Your Project

Project Title*

Please provide a title for your project

Does this material already exist within DH and just needs to be updated?

Select

Please attach copy of existing patient education or examples of desired patient education here.

Note that uploading a Word Document or other plain text format is best if possible
If you are submitting a request for a video, you must submit a script

Drag and drop files here or

Add any URLs (links) of current patient education or examples of desired patient education here.

If the existing material has a created date, please provide that date.

Creation Date

If the expiration date is known for existing material, please provide date.

Expiration Date

Please explain why this material needs to be modified, updated or is not in use.

Does content need further development? Is the information out of date?

What revisions are needed?

Project Details

Please give us as much detail on your project as possible so we can understand your request and assess how it fits into DH priorities.

Who is the audience you are trying to reach with this patient education request?

For example: pregnant women; adults diagnosed with asthma vs pediatric asthma, etc.

Does your patient population require translation of patient education materials?

*Please note that your department would be responsible for covering costs of translation services.

Select

Please select language(s) needed

If the language you are looking for is not listed, please select 'Other' and write it in

Select or enter value

If other language, please list

What sites across Dartmouth Health would benefit from this material?

Choose all that apply, and please note that we prioritize projects meant for the whole DH system

Select or enter value

If other, list which sites would benefit

Has a subject matter expert from your area reviewed this material?*

Subject matter experts are generally clinical trained staff who regularly work with patients and have particular expertise on the topic being covered in your patient education piece.

If yes, fill in name(s) and role(s) below.
If no, please identify a subject matter expert for this material below.

Please fill in the email of your subject matter expert.*

Please note: The future review of this project will be done by the subject matter expert (s) listed

Please fill in the role of your subject matter expert*

Are there barriers or challenges you would like to share?

Do you need this completed by a specific date?

If urgent, please explain further.

Note: We will be in touch to discuss prioritization and timing in more detail. Your response to this question is used to give us an idea of timing on your end. Our goal is to turn around all patient education requests as quickly and efficiently as possible while balancing it against our resources and capacity.

Select

Reason for Urgency

Select or enter value

If other reason for urgency, please explain

Date Needed

Is this work supported by a grant?

Select

Please fill name of grant below and describe any funding that might be available for development of this material.

Send me a copy of my responses

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