PATHFINDERS TASK FORCE
PATIENT EDUCATION MATERIALS
SUBMISSION FORM

See the Guidelines for Submitting Patient Education Materials
SEND TO:
Michelle Burns
Bone Marrow Transplant Unit
mjburns@nursing.umsmed.edu

Title of Material*
Date Submitted
Submitting Department
Extension Phone Number
UHHS Personnel Submitting Material
Signature (Specialty Physician/Hospital Chief Nursing Executive Officer)

For the purposes of displaying the educational material on the UHHS intranet, check the most appropriate category corresponding to the submitted material (Choose ONE category only):
Living With Your Body: diseases, prevention, wellness  
Important Facts About Your Medication: drug information  
Understanding Your Test or Procedure: surgery, diagnostic or therapeutic procedures (noninvasive or invasive)  
You and Your Therapies: physical, occupational, speech, respiratory therapies, etc.  
Adjusting to Your Illness: coping strategies, discharge planning  
Please state the purpose or intended use of the submitted materials
Do the submitted materials include any graphics, photos, or illustrations?   Yes [  ]  No   [  ]
If yes, do you have copyright permission documentation?
Was the submitted material generated by UHHS personnel?  Yes [ ]   No [  ]
If no, is there a disclaimer statement on the material?
Will any private company benefit from the use of these materials being distributed?  Yes [  ] No [  ]
If yes, please explain.

TASK FORCE REVIEW
Date: Signature:

*For UHHS-authored materials create brief titles that contain the word(s) which represent the disease, drug, procedure, therapy or main concept. Try to use that word as the first word of the title, if possible, so that it indexes appropriately for easy and fast searching. Example: "Using Your PCA Pump", Not "You and Your PCA Pump."