Teleheath Statewide Conference
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Reporting Information

REACH Telehealth Forms
(Printable forms in PDF)

The first four forms are to be used for every Telehealth encounter including training.

1. REACH Cover Sheet: Please fill out all fields to the best of your ability, including the names and roles of participants.
2. Pre-Conferencing Survey: This is to be completed prior to the Telehealth encounter; it measures the participants’ expectations of the quality of the upcoming encounter.
3. Post-Conferencing Survey: This is to be completed upon conclusion of the encounter. It measures the participants’ level of satisfaction as to the technical aspects of the encounter.
4. Informed Consent Cover Letter: Explains how the data provided by the above-mentioned surveys will be used. No action other than reading this form is required.
5. Consent to Participate in Telehealth Services: By signing this form, the parent or guardian gives consent for the Telehealth services. This form is to be filled out for each client for Telehealth clinical consultation.
6. REACH Activity Log: Completed monthly by site coordinator to document network partner activities.
7. Training Evaluation Form: This is to be completed upon conclusion the training. Each training participant completes this form to evaluate the training content.

Please fax these forms to:

REACH Program
(505) 272-0386

You may also mail to:

REACH Program
UNM Center for Development and Disability
2300 Menaul Blvd., N.E.
Albuquerque, NM 87107

If you have questions or concerns, call (505) 272-3844 or e-mail REACHCDD@salud.unm.edu. Thank you very much for participating in this program.

The forms listed on this page are available in Adobe Acrobat Portable Document Format (.pdf), and require Adobe Acrobat Reader.

You may download a copy of Adobe Acrobat Reader here.