Become a registered member of the coalition

Register for information about upcoming events or to get more intimately involved with the coalition. This registration form was designed to help coalition leaders manage participation efficiently and get participants involved in areas where they have demonstrated interest. Please take a few minutes to complete this questionnaire. Make sure to hit the "Submit" button at the bottom of the page when you are done.

Today's Date * Contact Name / Title * Contact Phone * Contact Email *	Area(s) of expertise (Care practice, workplace practice, environment, etc)
Nursing Home Information
Nursing Home Open-Door Mentor Program My nursing home has been successful in implementing one or more person-centered care practices and we are willing and interested in opening our doors to other nursing home professionals in Ohio so they can see how we did it. The coalition is free to distribute my name as a mentor contact in the areas specified below, and I am willing to answer questions from other professionals about them. Furthermore, my nursing home doors are open to anyone who would like to see policies in practice. (Important note: Please be sure to gain approval from the proper members of your organization's administration before selecting this option)
We are willing to share our successful person-centered practices in the following areas: Activities Program Bathing Experience Care Planning Dealing with Death & Dying Dementia Dining services Intergenerational programs Medication pass and/or schedule Mentoring program Neighborhood/community design Resident council Sleeping/waking schedules Staff recruitment, orientation, and/or retention practices Other practices:	Brief description of person-centered practices: *
Nursing Home Name	Nursing Home Address
Nursing Home City State Zip
Nursing Home County	Nursing Home Phone
What change(s) did you make in your home? How much time did it take to make the change(s)?
Describe your first steps in making the change(s).
List any barriers you encountered as you implemented the change(s). Briefly describe how you addressed those barriers.
What positive outcomes or successes have you enjoyed? (Change in clinical measures, impact on resident health or impact on turnover, etc.)
Please provide demographic information about your nursing home. Include bed size and whether you are located in an urban or rural area. Also tell us about the type of residents you care for.
How would you like other homes to contact you? List phone number or email address.
Are you willing to open your home to tours for other nursing homes? Yes No
Submit * = required