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Please complete and return via: (877) 250-2559 Local (916) 200-3886 [email protected] Planning Worksheet Questions? Call Don McCormick at (877) 646-5877 x 200 (9am-5pm PST) Does this Topper need a pre-printed:? Room# Room Phone# Neither Build-a-Board Design Tool Filename: Does this Topper need a 2nd language? Y N If yes, language: Orientation: e Contact Information: Your Name _______________________ Title _________________ Department ____________________________________________ Organization ___________________________________________ Address _______________________________________________ City _____________________ State _________ Zip ____________ Phone ( ) _________________ Fax ( ) __________________ Email _________________________________________________ q Topper Details: UNIT NAME/LOCATION: May we have permission to email or fax you about special savings or new product introductions? To correctly manufacture your Toppers, we need exact measurements. Measure the EXACT height and width of the INSIDE of your cur- rent Patient Care Board(s). w Stakeholders: How many individuals (including yourself) will be involved in the review and approval process?________________ Will your marketing or public relations department be involved in the review process? Yes No Quantity: INNER WIDTH: ________ “ H W INNER HEIGHT : ________ “ Portrait Landscape Y N Does this Topper need a pre-printed:? Room# Room Phone# Neither Build-a-Board Design Tool Filename: Does this Topper need a 2nd language? Y N If yes, language: Orientation: UNIT NAME/LOCATION: Quantity: INNER WIDTH: ________ “ H W INNER HEIGHT : ________ “ Portrait Landscape Does this Topper need a pre-printed:? Room# Room Phone# Neither Build-a-Board Design Tool Filename: Does this Topper need a 2nd language? Y N If yes, language: Orientation: UNIT NAME/LOCATION: Quantity: INNER WIDTH: ________ “ H W INNER HEIGHT : ________ “ Portrait Landscape Does this Topper need a pre-printed:? Room# Room Phone# Neither Build-a-Board Design Tool Filename: Does this Topper need a 2nd language? Y N If yes, language: Orientation: UNIT NAME/LOCATION: Quantity: INNER WIDTH: ________ “ H W INNER HEIGHT : ________ “ Portrait Landscape Does this Topper need a pre-printed:? Room# Room Phone# Neither Build-a-Board Design Tool Filename: Does this Topper need a 2nd language? Y N If yes, language: Orientation: UNIT NAME/LOCATION: Quantity: INNER WIDTH: ________ “ H W INNER HEIGHT : ________ “ Portrait Landscape Does this Topper need a pre-printed:? Room# Room Phone# Neither Build-a-Board Design Tool Filename: Does this Topper need a 2nd language? Y N If yes, language: Orientation: UNIT NAME/LOCATION: Quantity: INNER WIDTH: ________ “ H W INNER HEIGHT : ________ “ Portrait Landscape Does this Topper need a pre-printed:? Room# Room Phone# Neither Build-a-Board Design Tool Filename: Does this Topper need a 2nd language? Y N If yes, language: Orientation: UNIT NAME/LOCATION: Quantity: INNER WIDTH: ________ “ H W INNER HEIGHT : ________ “ Portrait Landscape Does this Topper need a pre-printed:? Room# Room Phone# Neither Build-a-Board Design Tool Filename: Does this Topper need a 2nd language? Y N If yes, language: Orientation: UNIT NAME/LOCATION: Quantity: INNER WIDTH: ________ “ H W INNER HEIGHT : ________ “ Portrait Landscape

Planning Worksheet - Healthcare Inspirations · PDF filePlanning Worksheet Questions? Call Don McCormick at (877) 646-5877 x 200 (9am-5pm PST) Does this Topper need a pre-printed:?

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Page 1: Planning Worksheet - Healthcare Inspirations · PDF filePlanning Worksheet Questions? Call Don McCormick at (877) 646-5877 x 200 (9am-5pm PST) Does this Topper need a pre-printed:?

Please completeand return via:

(877) 250-2559Local (916) 200-3886

[email protected]

Planning WorksheetQuestions? Call Don McCormick at (877) 646-5877 x 200 (9am-5pm PST)

Does this Topper need a pre-printed:?

�Room# �Room Phone# �Neither

Build-a-Board Design Tool Filename:

Does this Topper need a 2nd language?�Y �NIf yes, language:

Orientation:

e Contact Information:Your Name _______________________ Title _________________ Department ____________________________________________

Organization ___________________________________________

Address _______________________________________________ City _____________________ State _________ Zip ____________

Phone ( ) _________________ Fax ( ) __________________

Email _________________________________________________

q Topper Details:

UNIT NAME/LOCATION:

May we have permission to email or fax you about special savings or new product introductions?

To correctly manufacture your Toppers, we need exact measurements. Measure the EXACT height and width of the INSIDE of your cur-rent Patient Care Board(s).

w Stakeholders: How many individuals (including yourself) will be involved in the review and approval process?________________

Will your marketing or public relations department be involved in the review process? � Yes � No

Quantity:

INNER WIDTH:

________ “H

WINNER HEIGHT :

________ “

Portrait Landscape� �

Y N

Does this Topper need a pre-printed:?

�Room# �Room Phone# �Neither

Build-a-Board Design Tool Filename:

Does this Topper need a 2nd language?�Y �NIf yes, language:

Orientation:

UNIT NAME/LOCATION:

Quantity:

INNER WIDTH:

________ “H

WINNER HEIGHT :

________ “

Portrait Landscape� �

Does this Topper need a pre-printed:?

�Room# �Room Phone# �Neither

Build-a-Board Design Tool Filename:

Does this Topper need a 2nd language?�Y �NIf yes, language:

Orientation:

UNIT NAME/LOCATION:

Quantity:

INNER WIDTH:

________ “H

WINNER HEIGHT :

________ “

Portrait Landscape� �

Does this Topper need a pre-printed:?

�Room# �Room Phone# �Neither

Build-a-Board Design Tool Filename:

Does this Topper need a 2nd language?�Y �NIf yes, language:

Orientation:

UNIT NAME/LOCATION:

Quantity:

INNER WIDTH:

________ “H

WINNER HEIGHT :

________ “

Portrait Landscape� �

Does this Topper need a pre-printed:?

�Room# �Room Phone# �Neither

Build-a-Board Design Tool Filename:

Does this Topper need a 2nd language?�Y �NIf yes, language:

Orientation:

UNIT NAME/LOCATION:

Quantity:

INNER WIDTH:

________ “H

WINNER HEIGHT :

________ “

Portrait Landscape� �

Does this Topper need a pre-printed:?

�Room# �Room Phone# �Neither

Build-a-Board Design Tool Filename:

Does this Topper need a 2nd language?�Y �NIf yes, language:

Orientation:

UNIT NAME/LOCATION:

Quantity:

INNER WIDTH:

________ “H

WINNER HEIGHT :

________ “

Portrait Landscape� �

Does this Topper need a pre-printed:?

�Room# �Room Phone# �Neither

Build-a-Board Design Tool Filename:

Does this Topper need a 2nd language?�Y �NIf yes, language:

Orientation:

UNIT NAME/LOCATION:

Quantity:

INNER WIDTH:

________ “H

WINNER HEIGHT :

________ “

Portrait Landscape� �

Does this Topper need a pre-printed:?

�Room# �Room Phone# �Neither

Build-a-Board Design Tool Filename:

Does this Topper need a 2nd language?�Y �NIf yes, language:

Orientation:

UNIT NAME/LOCATION:

Quantity:

INNER WIDTH:

________ “H

WINNER HEIGHT :

________ “

Portrait Landscape� �

Page 2: Planning Worksheet - Healthcare Inspirations · PDF filePlanning Worksheet Questions? Call Don McCormick at (877) 646-5877 x 200 (9am-5pm PST) Does this Topper need a pre-printed:?

REFERENCES:1 Robert Wood Johnson Foundation “Improving Patient-Staff Communication Through White Boards.”

Voice Toll Free (877) 646-5877Email [email protected]

Web HealthcareInspirations.comMail 4225 Northgate Blvd. Suite 4 • Sacramento CA 95834

Since implementing white boards, Press Ganey scores im-

proved 2.5 points, resulting in a 5% increase in overall in-

stitution satisfaction.13

DIRECTOR, SERVICE EXCELLENCENORTH SHORE-LONG ISLAND JEWISH HOSPITAL

One of our key drivers as a hospital is to keep patients in-

formed. Implementing white boards as a communications

tool has put our nurses closer to the bedside and improved

information shared between our patients and their care

team. Using white boards has turned into a best practice.1

NURSE MANAGER

NORTH SHORE-LONG ISLAND JEWISH HOSPITAL

We are proud to be a Nurse and Veteran-owned business.