Welcome to the Patient Partner Innovation Network (PPIC) signup - 2.0

Thanks for your interest in joining PPIC!

Our network seeks participants interested in driving positive change in the healthcare system as a result of their lived experience as a patient, family member, caregiver, or community member. PPIC is also open to healthcare professionals who are interested and passionate about patient and family engagement, community engagement, and health equity. PPIC members have contributed to many healthcare improvement activities, including Technical Expert Panels (TEPs), focus groups, measure development and evaluation, validation of curriculum and research surveys, and co-development of health education materials and messaging.

To sign up for PPIC, please answer these initial demographic questions so we can learn more about you. We will not share or sell any information about you. We will contact you with engagement opportunities that may interest you. Each engagement opportunity is different, and you can decide which ones you want to apply to participate in based on the subject matter, time commitment, and honorarium.

Please contact us if you have any questions or want to learn more about us. Contact Desiree Collins Bradley at Desiree.Bradley@ATWHealth.com.

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* 1. First name

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* 2. Last name

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* 3. What is your preferred name or nickname?

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* 4. Email

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* 5. Phone number

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* 6. What is your preferred method of contact? (Choose all that apply)

Phone Call

Text Message (by selecting this option, you consent to receive PPIC-related text messages)

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* 7. What state do you live in?

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* 8. What kind of community do you live in? (Choose one)

Rural

Suburban

Urban

Tribal or Indigenous Communities

Other (please specify)

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* 9. What city do you live in?

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* 10. Languages Spoken (Choose all that apply)

American Sign Language (ASL)

Arabic

Cantonese

English

French

Fula

German

HIndi

Igbo

Italian

Japanese

Korean

Mandarin

Polish

Portuguese

Russian

Spanish

Swahili

Tagalog

Vietnamese

Yoruba

Prefer not to answer.

Other (please specify)

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* 11. Are you of Hispanic, Latino/a/x, or Spanish origin?

Yes

Prefer not to answer

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* 12. Race (Choose all that apply)

Indigenous/Native American, Alaskan Native, or First Nation

Asian

Black or African American

Pacific Islander or Native Hawaiian

White

Middle Eastern or North African (MENA)

Multiple Races

Prefer not to answer

Other (please specify)

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* 13. What is your age range? (Select one)

Under 18

18-24

25-34

35-44

45-54

55-64

65-74

75 and older

Prefer not to answer

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* 14. What is the highest level of education you have completed? (Choose one)

High school or equivalent

Some college

Associate’s degree

Bachelor’s degree

Master’s degree

Doctorate

Prefer not to answer

Other (please specify)

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* 15. Which of the following currently describes your military status? (Choose one)

Never been in the military

Currently on active duty

Currently in reserves

Veteran, no longer in the military

Prefer not to answer

Other (please specify)

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* 16. Which gender do you currently identify with? (Select one)

Female

Gender nonconforming, nonbinary, or other gender identity

Male

Transgender female (MTF)

Transgender male (FTM)

Prefer not to answer

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* 17. What is your sexual orientation? (Choose all that apply)

Lesbian, gay, or bisexual

Straight or heterosexual

Pansexual, asexual, questioning, or another sexual orientation

Prefer not to answer

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* 18. Have you experienced any of the following health conditions or situations? (Choose all that apply)

Cancer

Venous Thromboembolism (VTE) or Deep Vein Thrombosis (DVT)

Adverse Drug Event / Adverse Drug Event Complications

Anxiety

Asthma

Autoimmune Disorder

Behavior Health

Bipolar Disorder

C. Diff

Bronchitis

Catheter Associated Urinary Tract Infection (CAUTI)

Central Line-Associated Blood Stream Infection (CLABSI)

Chronic Obstructive Pulmonary Disease (COPD)

COVID-19

COVID-19 Vaccine Hesitancy

Dementia or Alzheimer’s Disease

Depression (major depression, dysthymia, or seasonal affective disorder)

Diabetes

Diagnostic Error or Delayed Diagnosis

Heart Attack or Other Heart Problems

High Blood Pressure (Hypertension)

HIV or Other Infectious Disease

Hospital-Associated Infection

Injury from fall and/or immobility

Kidney Disease

Living with a disability

Lower Back Pain

Low Bone Density or Osteoporosis

Maternal or Childbirth Adverse Event

Medication Error

MRSA Infection

Neurological Disorder

Obesity or other eating disorder

Post-Partum Depression

Orthopedic procedures or disorders

PTSD

Pressure Injury

Readmission(s)

Rare disease or condition

Sepsis

Sickle Cell Disease

Stroke

Substance Use Disorder (opioid use, alcohol, or other substances)

Surgical Site Infection

Ventilator associated event (VAE)

Prefer not to answer

Other (please specify)

None of the above

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* 19. What is your current healthcare coverage? (Choose all that apply)

Commercial Insurance (private or employer insurance)

Tricare (Military health insurance)

Medicare

Medicaid

Dual eligible for Medicaid/Medicare

Self-Pay

Uninsured

Underinsured

Insured through Healthcare.gov

Prefer Not to Answer

Other (please specify)

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* 20. What perspectives do you bring? (Choose all that apply)

Patient

Family caregiver

Advocate

Other (please specify)

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* 21. Do you have a healthcare story that you are willing to share with different audiences?

Yes

Maybe/not sure

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* 22. How did you hear about PPIC? (Select all that apply)

Online search

Social media

PPIC podcast

Referral from a friend, family member or colleague

Referral from a healthcare provider or organization

Received an email about PPIC

Other (please specify)

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* 23. ATW may contact me about PPIC engagement activities

I agree

I disagree

Thank you for joining our network. We look forward to engaging with you soon. Please know that the information you shared is secure and will never be sold or shared without your permission.