My Green Doctor

Green Meeting Notes Form

Please complete this short form after each staff meeting where you have discussed My Green Doctor topics.

• For each topic discussed, assign one person to be responsible for the topic.

• To qualify for the Green Practice Recognition Stage 1 Certificate - Culture of Sustainability, your practice must complete: 5 meetings, 5 Action Steps, & 5 Education Steps.

• Choose "Submit" at the bottom when you have completed this form and it will automatically be sent to My Green Doctor.

Name of healthcare practice: * Required

Clinic number:

Meeting date: * Required

Number of people at this meeting: * Required

Your name: * Required

Action Steps: Workbook topics we discussed at this meeting-please check all that apply. * Required

Workbook 1: Energy Efficiency

Workbook 2: Renewable Energy

Workbook 3: Water Efficiency

Workbook 4: Solid Waste and Recycling

Workbook 5: Drug Disposal and Chemicals

Workbook 6: Transportation and Commuting

Workbook 7: Health Foods in the Office

Other

Action Steps

Tell us what Action Steps or Education Step topics you discussed at this meeting and what was decided. We suggest discussing only ONE new topic per meeting, and IF THERE IS TIME REMAINING to discuss also the topics you are working on from prior months :

1st Action Step or Education Step topic discussed at this meeting: * Required

1st Action Step or Education Step: What was decided at this meeting? * Required

1st Action Step or Education Step: Who is leading this Action Step or Education Step (first name or initials, please)? * Required

2nd Action Step or Education Step topic discussed at this meeting:

2nd Action Step or Education Step: What was decided at this meeting?

2nd Action Step or Education Step: Who is leading this Action Step or Education Step (first name or initials, please)?

3rd Action Step or Education Step topic discussed at this meeting:

3rd Action Step or Education Step: What was decided at this meeting?

3rd Action Step or Education Step: Who is leading this Action Step or Education Step (first name or initials, please)?

4th Action Step or Education Step topic discussed at this meeting:

4th Action Step or Education Step: What was decided at this meeting?

4th Action Step or Education Step: Who is leading this Action Step or Education Step (first name or initials, please)?

5th Action Step or Education Step discussed at this meeting:

5th Action Step or Education Step: What was decided at this meeting?

5th Action Step or Education Step: Who is leading this Action Step or Education Step (first name or initials, please)?

Date for your next staff meeting to continue with My Green Doctor: * Required

Less Annoying CRM