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:

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

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




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?





All fields must be completed