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COMMUNITY PARTNERSHIP GROUP

MEMBERSHIP APPLICATION FORM

If you have been pregnant, or were the partner or family member of a pregnant patient, received care in Ontario and are interested in participating in the Community Partnership Group, please complete the information below.

What is Prenatal Screening? Did you have an ultrasound or blood test at 3 months to test your pregnancy for Down syndrome (also known as trisomy 21)? This is one form of prenatal screening, sometimes described as First Trimester Screening, Integrated Prenatal Screening or Maternal Serum Screening. Prenatal screening can also provide information about conditions other than Down syndrome, including trisomy 18 and trisomy 13.

Prenatal Screening Ontario is creating a Community Partnership Group made up of members of the public to understand the needs of the community and their experiences as it relates to prenatal screening. We are seeking advice from the public on educational material, quality assurance of the program, standards of care, and revised screening options that could be integrated into the current prenatal screening system.

Time Commitment

The business of the CPG will occur periodically and may be conducted as a face to face in-person meeting or teleconference. The majority of our ongoing work will be conducted by email.

We expect that face to face meetings will not happen more than once per year. Although it is preferable to attend meetings in person, electronic technology such as telephone and/or videoconferencing are available. Meeting dates and times will be determined by availability of the majority of members. A minimum of 50% of the membership is required for the meeting to be held.

If you have any questions about this process or about Prenatal Screening Ontario, please contact us at (613) 737-2281 or toll free 1-833-351-6490.

FIRST NAME: First name

LAST NAME: Last name

ADDRESS: Address

CITY: City POSTAL CODE: Postal Code

PHONE: Phone EMAIL: E-mail

How would you prefer to be contacted? (Please check all that apply)

Phone call ☐ Text ☐ Email ☐

WHAT IS YOUR EXPERIENCE WITH PRENATAL SCREENING? (Please check all that apply)

☐Patient ☐Partner/Family member of a patient

☐Prenatal Screening result low risk (negative) ☐Prenatal Screening result high risk (positive)

☐Screening declined ☐Consulted genetic services regarding screening results

☐Pregnancy with Down syndrome ☐Baby with Down syndrome

☐Pregnancy loss (miscarriage, stillbirth, neonatal death, termination)

☐Prenatal care by Midwife ☐Prenatal care by Obstetrician

☐Prenatal care by Family Physician

Other (please specify): Other

PLEASE TELL US ABOUT YOURSELF AND YOUR EXPERIENCE WITH PRENATAL SCREENING:

Explain

PLEASE DESCRIBE WHY YOU WANT TO BECOME A MEMBER OF THE COMMUNITY PARTNERSHIP GROUP?

Explain

WHAT DO YOU THINK ARE THE MOST IMPORTANT TOPICS THAT SHOULD BE ADDRESSED BY THIS GROUP?

Explain

WHAT TIMES AND DAYS WOULD BE CONVENIENT FOR YOU TO ATTEND MEETINGS? (Please check all that apply)

MONDAY

TUESDAY

WEDNESDAY

THURSDAY

FRIDAY

Morning

☐ ☐ ☐ ☐

Afternoon

☐ ☐ ☐ ☐ ☐

Evening

☐ ☐ ☐ ☐ ☐

DO YOU HAVE OTHER COMMENTS THAT YOU WISH TO SHARE WITH US:

Explain

APPLICANT’S SIGNATURE: Signature DATE:

Please email completed application form to Prenatal Screening Ontario at [email protected]

1

PSO-CPG Membership Application form

Adapted from CMNRP-FAC Membership Information Form

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