Patient and Family Advisor Application Form

First Name *

Last Name *

Address *

City *

State *

Zip Code *

Home Phone *

Cell Phone *

Email Address *

Preferred Method of Contact *

Home Phone

Cell Phone

Email

Please respond to the following questions to help us get to know you better.

Are you a... *

Patient

Family member of a patient

Employee

When was your care experience at this center? (Check all that apply.) *

What language(s) do you speak? *

Which unit or service provided care for you or your family member: (check all that apply) *

We recognize that our patient and family advisors have busy lives. How much time are you able to commit to being a patient and family advisor? (Check one) *

Less than 1 hour per month

1 to 2 hours per month

3 to 4 hours per month

More than 4 hours per month

Are you available to serve as an advisor for at least 1 to 2 years? *

Yes

No

How do you want to help? (Check all your interest areas.) *

Help develop or review informational materials for patients and family members

Help improve patient safety and the prevention of medical errors

Help improve the patient and family role in care decision making

Help improve the healthcare facilities (i.e. patient care areas or family resource room)

Help educate or train healthcare staff and clinicians

Review procedures and provide input to improve the care center admission process

Provide input in areas like bedside shift report, where nurses who are going off duty share information with nurses coming on duty at the patient’s bedside

Review procedures and provide input to improve transitions in care (i.e. between hospital units or discharge from hospital to home health)

Other

Please tell us about yourself.

Why do you want to become a patient and family advisor?

Please briefly describe any experience you may have as an advisor, as an active volunteer or as a public speaker.

Please describe any specific things that doctors or caregivers did or said while you or your family member were receiving care that were helpful to you or your family.

Please describe any specific things that doctors and caregivers could have done differently to be more helpful to you or your family member?

Our patient and family advisors reflect the diversity of the patients and families we serve. Please share anything about yourself that you think would add to the diversity of our team of advisors.

To find a physician or for questions 903-596-DOCS

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Patient and Family Advisor Application Form

Please respond to the following questions to help us get to know you better.

Please tell us about yourself.