Homeward Bound Heroes Submission Form

This form allows Activity Directors to submit Homeward Bound Heroes stories and pictures.

We are attempting to get positive social media out in regards to our short term residents stay at the facility during these COVID-19 times. Most people have a stigma in regards to going to a nursing home for rehab/recovery during this time due to negative LTC facility press. In an effort to change that, we would like to have stories with Sub-acute residents photos showing them with a positive expression (Smiling, waving, giving the thumbs up or holding the attached sign or a sign they personal wrote) that depicts them feeling safe and free of COVID-19 while residing in the facility.

The resident must sign a photo release form and try to capture the resident in his or her room with a nice background, with clean clothing on. No mask is required if they are in their room alone. No oxygen tubes, preferably not in a walker or wheelchair if possible. Sitting in a chair would be best if standing is not an option.

We would like this to be completed as soon as possible prior to their d/c.

The following questions should be asked so we can create a story or quote from them:
Submittor Details
Submittor Name*
Enter your name.
Submittor Email*

Please enter your Alaris email so that we may contact you regarding this submission if need be.
Homeward Bound Hero Details
Facility*

Please select facility the event was held at.
Name of Patient*
Enter the name of the patient.
Questions for the Patient
1) Were you nervous about coming to a rehabilitation facility during these difficult times?*
2) Was your family supportive of you coming?*
3) What did you experience when you arrived?*
4) Were you able to stay connected to your family and loved ones during your stay?*
5) Did you feel the staff kept you safe and protected you during your stay?*
6) How was your therapy and treatment during your stay?*
7) What was your most successful part of your treatment?*
8) What would you like to tell other potential residents who might be afraid of coming to a nursing rehab center?*
9) Did any particular staff member(s) make your stay particularly special?*

Please include staff member name and position.
Upload Image(s)
Did the resident sign a photo release form?*
- Yes
- No
Image(s) Upload*
Drop files here or
Upload images of the resident.
Phone
This field is for validation purposes and should be left unchanged.

Homeward Bound Heroes Submission Form

Submittor Details

Homeward Bound Hero Details

Questions for the Patient

Upload Image(s)