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Patient Voice Representative Reporting Form

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Please fill out this form after each event where you represent the CCAN Patient Voice. If this is an ongoing placement (committee, etc), please fill out this form quarterly.

Your Information

Your Name (required)

Your Email (required)

Please tell us about the host organization.

1. What is the mandate of the host organization?

2. What services, information or networks are provided by the host organization, which may be of interest to CCAN and its members?

3. Please share any news or recent activities of interest of the host organization.

Please tell us about the event(s) you participated in.

4. What was the main message garnered from this event?

5. Please provide a summary of your presentation/representation on behalf of CCAN at this event.

Any other information to share?

6. Tell us more about the host organization, the event itself, the other participants, or provide any other feedback.