Patient and Family Advisory Council (PFAC) Application Name First Last Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAntigua and BarbudaArgentinaArmeniaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBosnia and HerzegovinaBotswanaBrazilBruneiBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCosta RicaCôte d'IvoireCroatiaCubaCuraçaoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEast TimorEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFaroe IslandsFijiFinlandFranceFrench PolynesiaGabonGambiaGeorgiaGermanyGhanaGreeceGreenlandGrenadaGuamGuatemalaGuineaGuinea-BissauGuyanaHaitiHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsraelItalyJamaicaJapanJordanKazakhstanKenyaKiribatiNorth KoreaSouth KoreaKosovoKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMauritaniaMauritiusMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew ZealandNicaraguaNigerNigeriaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaSaint Kitts and NevisSaint LuciaSaint Vincent and the GrenadinesSaint MartinSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSpainSri LankaSudanSudan, SouthSurinameSwazilandSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTogoTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVatican CityVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.YemenZambiaZimbabwe Country Primary PhoneSecondary PhoneEmail Is English the language you primarily use when communicating?YesNoWhat is your primary language?Are you able to attend meetings at Hamilton Medical Center during weekday evenings (dinner will be provided)? * RequiredYesNoAre you willing to provide immunizations records (if born AFTER 1957) to serve on the Patient and Family Advisory Council? * RequiredYesNoAre 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? * RequiredYesNoAre you willing to undergo a background check? * RequiredYesNoPlease tell us which activities you might be interested in: * Required Reviewing policies/procedures 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 Secret Shoppers OtherPlease describe areas you would like to serve in:Please tell us about your experience(s) at Hamilton Medical Center (HMC)Have you ever been hospitalized at HMC for more than 24 hours? * RequiredYesNoIf 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? * RequiredYesNoIf 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?