Carolinas HealthCare System

TeachWell Confirmation & Commitment Form

The TeachWell Confirmation & Commitment Form provides CHS nursing and other staff a means to confirm training on the use of Teach Back and Ask Me 3, two evidenced-based best practices, and make a commitment to using both health literacy practices.

First Name:
Last Name:

Facility/Network/Other:
Practice/Unit/Dept/Other:
Inpatient/Outpatient:
Clinical/Non-clinical:
Role:

Prior to participating in TeachWell, did you have training in Teach Back?	YesNo
Prior to participating in TeachWell, did you have training in Ask Me 3?	YesNo

What was the learning environment/format that you received TeachWell training? (Select all that apply)

Online module or webinarTeachWell Playbook & Tools
Small group, team-based settings (i.e. staff huddles/staff meetings)Classroom Training
Other

On average, what percentage of your work day is spent in direct communication with patients and/or caregivers?

On average, how often do you think you will incorporate TeachWell techniques during your patient and/or caregiver communications?

By signing this form, I attest that the information I provided is complete and accurate. In addition, I commit to driving system-wide change and improvement of patient care at CHS by closing the gap between what I communicate to patients and what our patients understand. I will do this through ongoing use of Teach Back and Ask Me 3.

All fields must be completed