programs - amputee rehab center - amputee rehabilitation

Français
Meet our Peer Visitors | Contact Us | Site Map

Peer Visitor Program | Support Groups | PALS | Future Projects

Planning a peer visit | Following the visit

The following information is strictly confidential and will not be communicated to anyone under any circumstances .It will be used only by the Peer Visitor Program to validate the usefulness of the visits and maintain contact with the amputees who are interested in being contacted.

* Name of the peer visitor :

* Date of the visit :

Information : name of the person visited and place of the visit

* Name

Address :(where visit is held)

* Phone number : (for the visit)

Peer visit reporting form

It is important to return this questionnaire. It is meant to help you and the Peer Visitor Program improve. . We greatly appreciate your answers and comments.

The visit

Type of visit:

Personal Visit

Phone Visit

Duration of the visit:

Time needed for transportation :
(if pertinent)

Does the IND wish a follow up visit

Yes

Following the visit

		N/A	Agree	Disagree
1.	I had all the information I needed before the visit (from the referral)
2.	The IND had invited me to visit with him/her.
3.	The IND and I were matched appropriately (age, gender, cause of amputation, type of amputation, etc).
4.	The visit took much longer than I had anticipated.
5.	There were several unexpected questions or topics that were brought up during the visit.
6.	I was prepared for most of the questions that were asked.
7.	The IND was receptive to the information and sharing experiences
8.	There were other family members/friends/loved ones present for the peer visit.
9.	The IND was interested in more information about peer support including (support groups, additional peer visits, social interactions with other amputees).
10.	I felt comfortable throughout the peer visit (place, discussion, interaction, etc).
11.	This was the first visit with an amputee for the IND.
12.	I think the Peer Visit went well.

Additional comments, suggestions and feedback

Your feedback is greatly appreciated

Please recopy the security code

* mandatory field