Narcolepsy Network, Inc.
10921 Reed Hartman Hwy, Suite 119
Cincinnati, OH 45242
(513) 891-3522; (513) 891-3836 fax
This form is for members who have registered online
or who have not previously completed this Survey of Skills. Please print this
form, complete and mail to the above address. Thank you!
Name Phone E-mail
(Requested of new members only, or renewing members who have not
previously completed.)
We are a nonprofit patient organization, governed by and existing for our members. We wish to be an expanding network, serving present members and extending our resources to all persons with narcolepsy. Your personal interests and participation are important. Please help us by completing this brief survey.
I. INTERESTS
A. My primary interest in narcolepsy is ____ for myself, ____ for a family member or friend, ____ professional
B. We often receive requests from persons with narcolepsy for names and contact information of others with narcolepsy who live in a certain area or who share a common interest.
1)____You may provide my: ____
name, ____ phone
number, ____ address, ____ e-mail to others.
2)____ Please keep my name, phone number, address, e-mail strictly
confidential.
C. 1) I presently a)____ take part, b)____ do not take part, c)____ wish to take part in a support group
2) I ____ am willing, ____ not willing to co-lead and/or assist in the development of a new support group
II. NEEDS
The greatest benefits I hope to receive from this organization are, in order of importance, the following:
1) 2)
3) 4)
III. SKILLS
Highest Educational Level Main Work Experience
I have the following interests, experience, abilities, or professional skills in which I am willing to volunteer in order to improve our organization?s network, resources, and programs on behalf of all persons with narcolepsy.
1) ____ contacting other members with important information: a) ____ telephone; b) ___ letter; c) ___ e-mail
2) ____ contacting state and federal legislators: a) ____ telephone; b) ___ letter; c) ___ e-mail
3) ____ distributing educational materials to schools, libraries, health fairs, etc.
4) ____ personally meeting newly diagnosed persons with narcolepsy
5) ____ being available for interviews by media reporters: a) ____ newspaper; b) ___ magazine; c) ___ T.V.; d) ___ internet
6) ____ writing personal and/or informative articles for: a) ____ newspaper; b) ____ magazine; c) ___ internet
7) ____ appearing to talk about narcolepsy: a) ____ schools; b) ____ colleges; c) ____ civic groups; d) ___ health care groups
8) ____ I have, from my training or experiences, professional or special skills in which I am willing to provide for activities of Narcolepsy Network. (Please describe)
a) ____ fundraising; b) ____ accounting; c) ____ legal; d) ____ writing; e) ____ graphic; f) ____ layout;
g) ____ filming; h) ____ website design; i) ____ programming; j) ____ health care; k) ____ research;
l)
____ other:
9) ____ I am willing to assist these
Narcolepsy Network committees and programs
a) ____ Advocacy (tracking and assisting in response to laws and issues affecting persons with narcolepsy)
b) ____ Conference (assisting in planning and conducting national and local conferences)
c) ____ E-mail (receive and correspond to e-mail questions and communication from members and others)
d) ____ Fundraising (develop and help implement local and national fundraising projects)
e) ____ Membership (outreach to invite new members and to develop support groups)
f) ____ N[ART] (create and contribute to artistic expressions representing narcolepsy)
g) ____ Newsletter (writing, illustrating, printing and layout of quarterly newsletter)
h) ____ Publications (review, write, design and plan new educational materials)
i) ____ Website (design, maintenance, contribution to our website, and review of others)