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Order Number

First Name *

Last Name *

Email Address *

Mobile Number (to be contacted if question about claim)

Medical Staff Type *

GP Specialist

Are you registered with FEMS? *

Yes No

Meeting Name *

Meeting Purpose *

Meeting Date *

Start Time *

End Time *

Number of hours claimed *

Please indicate what objectives of the Facility Engagement Initiative’s Memorandum of Understanding were met, if any (check all that apply): *

To improve communication and relationships among the medical staff so that their views are more effectively represented.

To prioritize issues that significantly affect physicians and patient care

To support medical staff contributions to the development and achievement of health authority plans and initiatives that directly affect physicians.

To have meaningful interactions between the medical staff and health authority leaders, including physicians in formal HA medical leadership roles.

Please identify the type of engagement that was achieved during this event (pick only one!): *

I was informed by being provided with information on an activity, project or policy

I was consulted to obtain feedback on key decisions or activities, and informed (or will be informed) of how my feedback will be used

I collaborated with decision makers to provide my advice, leadership and recommendations on a project, activity or policy

I was empowered to be a joint partner in decision-making on a project, activity or policy.

How could this event be improved? Other Comments *

Multidisciplinary meeting (i.e. not physicians only).
Meeting focused on LMH Operations (LMH patient care, quality, work environment).
Invited by LMH Manager, Senior Admin, or Dept Head.
Participation not implied by reason of title (eg Dept Head) or for maintenance of privileges.
Not already being reimbursed for participation via another funding source.

Please list name of person requesting your attendance: *

Approved payments will be calculated using current GPSC/SSC sessional rates. Time rounded to nearest ¼ hour.
Approved payments will be direct deposit via LMH Facility Engagement Management System (FEMS) and Versapay. Go online to fems.facilityengagement.ca and versapay.com ; and follow instructions to enrol.
Payment will be contingent on LMH FE funding availability for this initiative in the given fiscal term.
Deadline: Claim forms must be submitted within one month of the meeting date.
Repeated (>6) meetings (eg monthly committee meetings) are asked to submit separate LMH FE Project Intent (Project Intent forms available upon request from lmhpa@facilityegagement.ca or https://msalmh.ca/physician-enagement/facility-engagement/)