Patient and Family Advisor Application

Patient and Family Advisor Application Form

Name *

First

Last

Street Address *

Town *

Province *

Postal Code (ex. X1X 1X1) *

Phone Number (ex. 709-555-5555) *

Checkboxes *

Home
Cell

Email

Preferred method of contact *

The next set of questions will help us to know you better

I am a: *

The last care experience I or my family member received at Labrador-Grenfell Health was in: *

2021
2020
2019
2018

If you chose "Other" above, please indicate additional languages spoken.

We recognize that our Patient and Family Advisors have busy lives. How much time are you able to commit to being an Advisor? (Please choose one option) *

Less than 1 hour per month
1 to 2 hours per month
3 to 4 hours per month
More than 4 hours per month

How do you want to help? I want to contribute in the following ways: (Check all that apply) *

Story Sharing: Share your story with health care providers, staff and other patients
Advisory Capacity: Serve as a member on regional committee(s)
Committee Work – Participate on specific Program Committees
Short- term Projects: Partner with staff on short term projects or focus groups to help improve services
Online Advisor: Respond online to questions/surveys about patient care and how care can be improved
Hospital Facilities – provide input to help improve patient care areas, new facility construction, etc.
Educational Materials – Developing/reviewing patient and family education materials and website
Policy & Procedure Input: Review procedures and provide input to improve processes.
Other

If you chose "Other" please describe your suggestions:

What are some areas/issues that are of special interest to you? *

Why would you like to serve as a Patient and Family Advisory? *

Please read carefully and confirm the following by checking the boxes *

I understand that by submitting this application and/or being interviewed does not guarantee a position as a Patient and Family Advisor.

Checkboxes *

I understand that prior to beginning as a Patient and /or Family Advisor, I must sign a Confidentiality Agreement

Date: (ex. January 1, 2021) *

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