User Information and Registration Form



The Toolkit of Instruments to Measure End-of-Life Care (T.I.M.E.) is copyrighted material. However, you are free to use it, in full or as individual items, adapt it to your local circumstances, or reproduce it without charge providing that you complete the following registration form and agree to the following conditions.

 

  1. Both the Toolkit of Instruments to Measure End-of-Life Care and Dr. Joan M. Teno, MD, MS, will be acknowledged in any publication, report, or oral presentations.


    2.
  2. If T.I.M.E. is copied for others, you undertake responsibility to ensure they agree to the user registration form and return this to Dr. Teno.


    3.
  3. T.I.M.E. will not be sold, either in its original or adapted form.

 

By checking the box below and typing your initials, you are agreeing to the terms set forth above.

I agree to the above conditions.
Initials:
Date:

Name:

Street Address:

City:

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Location where you will use T.I.M.E. (please check that apply):


Hospice

Hospital

Nursing Home

Other (please specify):

 

Do you plan to use T.I.M.E. (please check appropriate response)?


Yes, definitely

Probably

Not sure

Probably not

No, definitely not

To submit this form via e-mail, press the "Submit" button below, or you may "Reset" the form and begin again.

 

If you prefer to submit via fax or mail, please click here to download the registration form as a PDF file. You can then print it out and mail or fax it to:

Dr. Joan M. Teno, MD, MS
Center for Gerontology & Health Care Research
Brown Medical School
167 Angell Street, Lower Level
Providence, RI 02912
Fax: 401-863-1742.

NOTE: Viewing this PDF file requires Adobe Acrobat Reader 4.0 or greater. If you do not have Acrobat Reader installed on your machine, click here to go to Adobe's webiste and download the reader for free.

 


Funding for this project was provided by
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This web site is published by the Center for Gerontology and Health Care Research, Brown Medical School. For further information, e-mail Dr. Joan Teno or contact her at Brown Medical School, Box G-HLL, Providence, RI, 02912, USA. For questions or comments regarding this website, please e-mail the webmaster. Last edited February 17, 2004.