EXPRESSION OF INTERESTAPPLICATION FORM
CENTRAL EAST HOSPICE PALLIATIVE CARE NETWORK MEMBERSHIP
SECTION A: Guidelines for Submission- Review the Central East Hospice Palliative Care NetworkTerms of Reference prior to completing Expression of Interest.
- Applications will not be considered if all fields are not completed.
- Applicants must attach a copy of their most recent resume.
- Applications must be sent electronically to
- Include your Name and CEHPCN Membership Expression of Interest in the subject heading.
SECTION B: Personal Contact Information
Name
Address
Phone Number
SECTION C: Work Place Information
Name
Address
Phone Number
Specify Central East LHIN location/cluster.
Scarborough Cluster
Durham Cluster
North East Cluster
LHIN Wide (Please specify)
SECTION D: Experience (Past Present)
Settings in which Death Occurs / Organization Name and Description of Position
Hospital (General)
Hospital (Palliative Care Unit)
Long Term Care Home
Retirement Home
Community (Home)
Residential Hospice
Other (Please specify)
General Population / Description of Experience with Population
Children (0-10)
Youth (11-20)
Adults (21-64)
Seniors (65+)
Volunteer Experience
Describe any volunteer experience you have in relation to hospice, palliative and end of life care.
SECTION E: Network/Committee Participation
1)What experience do you have with professional Committees, Working Groups and or Networks?
2)Describe how you would provide direction and leadership for coordinating activities and making decisions on behalf of the CEHPCN?
3)Describe how you would initiate and coordinate projects that support the development and evolution of a comprehensive, integrated and coordinated system of hospice palliative care for the Central East Region.
4)How would you meaningfully engage members of the Network (i.e. stakeholders relevant to hospice palliative care); plan for and provide opportunities for them to interact and collaborate; develop communications to Network members and the broader community.
Meeting Participation
Generally, meetings are held during daytime hours however please specify the following:
If selected, I would be able to attend meetings during the early morning hours (7-9am).
If selected, I would be able to attend meetings during daytime hours (9-5pm).
If selected, I would be able to attend meetings during evening hours (5-7pm).
If selected, I would be able to participate in meetings by teleconference/video conference (i.e. via OTN).
SECTION F: Desirable Skills
Based on your experience, describe how you would meet the below targeted skill sets?
Quality Improvement
(E.g. Promoting population health, patient experience, cost control)
System Planning
(E.g. Linking population need, provider capacity and government policy)
Strategic Planning
(E.g. Process of defining organizational strategy, direction and resource allocation)
Facilitation & Team Leadership
(E.g. Taking initiative to complete collective goals, resolves conflicts and coordinate team efforts)
SECTION G: Community Awareness
Describe any unique characteristics and or palliative and end of life care challenges faced by your community?
SECTION I: Signature and Declaration of Information
Information requested in this form will be used ONLY by the Selection Committee to evaluate the sustainability of all potential candidates for appointment to the Central East Hospice Palliative Care Network Membership, and will not be disclosed without the consent of the applicant. Additional disclosures of personal information may be separately requested in order to evaluate the sustainability as a candidate as well as to verify the accuracy of the information you have provided and for no other purposes. Any questions about the collection, use or disclosure of personal information requested on this application should be directed to .The signature below declares the information submitted for the purposes of this Expression of Interest to be true.
SIGNATURE: / DATE:
CEHPCN MEMBERSHIP APPLICANT EXPRESSION OF INTEREST, Page 1 of 3