Index/Order Form of Materials Please note - Pain Resource Center ...

- Psychosocial Pain Assessment Forms in Spanish (for adults and children/adolescents):Spanish – Adults: http://prc.coh.org/pdf/Forma%20%20Adultos%20PS.pdf.Spanish – Children/Adolescents: http://prc.coh.org/pdf/Formulario%20Ninos.pdf.28. Quality of Life Instruments - City of Hope, Duarte, CA- Bone Marrow Transplant – is an 84-item tool specific for use in BMT.- Breast Cancer Patient Version – is a 46-item tool specific for use in Breast Cancer- Quality of Life Patient Version – is a 41-item instrument that measures QOL of a patient with cancer. Also includesSpanish version of instrument.- Quality of Life Family Version – is a 37-item instrument that measures QOL of a family member caring for a patientwith cancer. Also includes Spanish version of instrument.- Quality of Life Ostomy Version – is a 43-item tool specific for use in Patients with an Ostomy- Staff Survey on Ostomy Care - a 32-item tool specific for staff- Ovarian Cancer Patient Version – is a 45-item tool specific for use in Ovarian Cancer. Includes Spanish version.- Patient/Cancer Survivor Version – is a 41-item ordinal scale that measures quality of life through physical,psychological, social, and spiritual domains. This tool has been used extensively in pain and cancer survivorshipresearch. Also includes Spanish version of the instrument.- Quality Care at the End of Life Survey – This survey was designed based on the National Consensus Project forQuality Palliative Care Guidelines and was developed and used at the City of Hope as a tool for assessing qualitycare. Users are invited to adapt and use it in their own institutions to assess the quality ofcare provided and to measure the institution’s performance in comparison with national guidelines.- Thyroid Version - is a 34-item tool specific for use in Thyroid Cancer.Website: http://prc.coh.org/res_inst.asp. (# 28)29. RN Needs Assessment: Pain Management - University of Wisconsin Hospitals & Clinics, Madison, WI- This two-page survey assists in planning continuing education programs in pain management for nurses.Website: http://prc.coh.org/html/rn_needs.htm.30. Rehabilitation Professionals’ Knowledge and Attitudes Survey Regarding Pain – Boston School of Occupational Therapy,Boston, MA- This instrument was developed as an inter-disciplinary tool to assess knowledge and attitudes regarding pain inrehabilitation professionals. This tool was developed using the OT/PT IASP Pain Curriculum in conjunction with 6clinical experts.Website: http://prc.coh.org/html/rehab_professionals.htm.31. Survivorship Needs Assessment ToolsSurvivorship Care Summary/Plan:- American Society of Clinical Oncology (ASCO)Website: http://pda.asco.org/patient/Survivorship/ASCO+Cancer+Treatment+Summaries Generic template- Journey Forward Care Plan Builder Website: www.journeyforward.org- Livestrong Care Plan-Furnished by Penn Medicines Oncolink Website: http://www.oncolink.com/oncolife/- NCI Community Cancer Centers Program (NCCC) Breast Cancer Survivorship Care Plan 08/08Website: http://ncccp.cancer.gov/NCCCP-ASCO-Breast-Cancer-Survivorship-Care-Plan.pdfSurvivorship Needs Assessments:- Cancer Survivors Survey of Needs - Mayo Clinic Cancer CenterWebsite: http://prc.coh.org/Survivorship/P-Mayo%20PCCC.pdf- Transition Plan for Cancer Survivors: Survey of Needs - Pearlman Cancer Center, Adapted from Mayo Clinic CancerCenterWebsite: http://www.sgmc.org/Pearlman-mayo- Survivor Needs Assessment (English) - St. Luke’s Hospital and Health NetworkWebsite: http://prc.coh.org/Survivorship/St%20Luke%20Eng.pdf- Survivor Needs Assessment (Spanish) - St. Luke’s Hospital and Health NetworkWebsite: http://prc.coh.org/Survivorship/StLuke%20Span.pdf- Survivor Assessment Tool (Patient) - University of Tennessee Medical Center Cancer InstituteWebsite: http://prc.coh.org/Survivorship/SAT-PT.pdf- Survivor Assessment Tool (Physician) - University of Tennessee Medical Center Cancer InstituteWebsite: http://prc.coh.org/Survivorship/SAT-MD.pdf.100