PFAC – Patient/Family Candidate
Patient and Family Advisory Council (PFAC)
|*Starred fields are required|
|First Name:*||Last Name:*|
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|Primary Phone:*||CellWorkHome||Secondary Phone:||CellWorkHome|
|Do you feel comfortable working in groups, speaking up and providing input?|
|Is English the language you primarily use when communicating?
If your answer is no, what is your primary language?
|Are you able to attend meetings at Hamilton Medical Center during weekday evenings (dinner will be provided)?
|Are you willing to provide immunizations records (if born AFTER 1957) to serve on the Patient and Family Advisory Council?
|Are you willing to sign an agreement promising not to disclose confidential information given to you in your role as a member of the Patient and Family Advisory Council?
|Are you willing to undergo a background check?
|Please tell us which activities you might be interested in:
Improving the hospital experience for patients and their families
Development of educational materials for patients and their families
Improving patient safety
Serving on hospital committees as a Patient and Family Advisor
Facilities and equipment upgrades
|Please tell us about your experience at Hamilton Medical Center (HMC)|
|Have you ever been hospitalized at HMC for more than 24 hours? Yes No
If your answer is YES, how long was your longest hospitalization?
|Have you ever been a care-giver for a patient who was hospitalized at HMC for more than 24 hours? Yes No
If your answer is YES, how long was the longest hospital stay of the person you were caring for?
|Approximately how many times have you or someone close to you had a hospitalization experience at HMC in the last three years?|
|How would you describe your hospital experience at HMC?|
|What did HMC do well during your stay or your loved one’s stay?|
|What could HMC have done better during your stay or your loved one’s stay?|
|What would you like the HMC to learn from your stay or your loved one’s stay?|