Volunteer Patient and Family Advisor Application

Personal Information

* Last Name

* First Name

Middle Name

* Date of Birth

Citizenship Status Required:

U.S. Citizen

Permanent Resident

Neither

Current Address:

* Street

* City

State

* Zip Code

Telephone Number(s) with area code:

Day

Evening / Home

Cell

* E-mail address:

Emergency Contacts

* Name:

* Relationship to you:

Telephone Number:

* Cellular Number:

Physician's Name:

Hospital Affiliation:

Physician's Telephone Number:

Volunteer Information

The following questions will help us get to know you better.

* Are you an employee of UHealth?

Volunteer Type

What language(s) do you speak?

Are you a patient, former patient, or a family member of a patient?

When was you or your family member's care experience at UHealth?

Where did you or your family member receive care (check all that apply)?

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

Are you available to serve as an advisor for at least 1 to 2 years? You can still be an advisor if you answer 'No'.

How do you want to help? Check all areas of interest.

Serve as a member of the Patient and Family Advisory Council (PFAC). Potential advisory council members should be available to commit to serving on the Council for at least 1 to 2 years. The PFAC may meet once a month for 1.5 to 2 hours.

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 hospital facilities (for example, patient care areas, or a family resource room).

Help educate or train hospital staff and clinicians.

Review procedures and provide input to improve the hospital processes.

Review procedures and provide input to improve transitions in care (for example, between hospitals units or discharge from hospital to home).

Other issues (Please describe):

Signatures

I certify that all statements in this application are true. I also agree that if I am accepted as a volunteer, I will abide by all regulations of UHealth.

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Applicant's Signature