Dear OAB Visitor:

You are currently on our list as available to volunteer your time to help those in need during periods before and subsequent to ostomy surgery or continent procedure.

We are in the process of re-developing our Service, and are attempting to engage enthusiastic volunteers.  Some of you have been continuing, over many years, your excellent support and inspiration to those in need.  Others of you are no longer able to serve in this capacity, and may wish to be taken off our list of volunteers.

Please submit the following form.  If you do not respond, we will assume that you are no longer available to provide Visiting Services.

Name:           
Address:       
City:              
State:              
Zip:                

Do you wish to continue to Visit patients?
Yes
No
(Check One) If you answered "No",  you may, if you wish, stop here and complete.
To complete survey, press the submit bottom at the bottom of the screen.

What experiences have you had visiting patients?  If positive state why.  If negative explain.

For how many years have you visited patients?   


What type of surgery have you had? Describe type of ostomy, and date (s) of ostomy surgery or surgeries.

 

How long has it been since you were ill or recuperating from ostomy surgery or continent procedure?

 

What is your age?                                    What is your marital status?


Would you be willing to update your skills by participating in the Visitor Training Program on Saturday, Jan. 22, 2005?
Yes
No                   If no, please state reasons why.

Are you a Member of OAB? If no, please state reasons why. 
Yes
No

 

If you are not an OAB member, would you be willing to become one in order to continue visiting patients?

 

How are you most easily reached?
telephone            email


Home Telephone #:              Work Telephone #:      
Which telephone is best to reach you Home      Work

E-Mail:                      

We are trying to strengthen our relationships with ET/WOCNurses by providing rapid response to their requests for visits, as well as by providing visitors who are willing to see the patient in the hospital, or subsequent to discharge.. Would you be willing to go to patients who request to meet with you directly?
Yes
No

Are you able to commit to making your initial Visitor contact either by phone or in person within 24 hours of receiving the request from OAB?
This contact can be with either the patient or the caregivers making the referral.
Yes
No

Comments:

You may call me directly or email me with suggestions or concerns at the number and email address below.

Thank you very much for all you have given to OAB.  We look forward to gratifying and creative collaboration with you as we work to rebuild our Visitor Services Program.

Martha Heller (617) 332-4625
Nina Mintzer (781) 769-3299

Last updated December 5, 2004