Patient and Family Advisory Council Application

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* 1. FIRST NAME

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* 2. LAST NAME

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* 3. STREET ADDRESS

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* 4. CITY

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* 5. STATE

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* 6. ZIP CODE

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* 7. HOME PHONE

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* 8. CELL PHONE

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* 9. EMAIL

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* 10. LANGUAGE(S) YOU SPEAK

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* 11. I AM...

A Patient

A Family Member of a Patient

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* 12. DATES CARE PROVIDED WITH HONORHEALTH CANCER CARE

2022 to present

2020 to present

2018 to 2020

Earlier than 2018

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* 13. HAVING ACCESS TO CANCER SUPPORT GROUPS, ONCOLOGY SPECIFIC HEALTH & WELLNESS OR HEALTHY LIFESYLE CLASSES WOULD BE A GOOD OFFERING AND CONTRIBUTOR TO THE CANCER CARE JOURNEY IF OFFERED

IN-PERSON AT HONORHEALTH

IN-PERSON AT A CANCER SUPPORT COMMUNITY PARTNER OF HONORHEALTH

VIRTUALLY

I WOULD NOT HAVE PARTICIPATED IN THIS

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* 14. WITHIN THE LAST TWO YEARS, WHAT HONORHEALTH SERVICES HAVE YOU OR YOUR FAMILY MEMBER USED? *Indicates Cancer Care Services

*Breast Surgical Oncology

*Gynecologic Oncology

*Medical Oncology & Hematology

*Radiation Oncology

*Surgical Oncology

*Urology Oncology

*Genetics

Chest/Pulmonary

Ear, Nose, Throat

Endocrinology/diabetes

Eye

Gastroenterology/GI

Genetics

Intensive Care (ICU)

Infectious Disease

Primary Care Medical Group

Neurology

Orthopaedic

Pregnancy/Childbirth, Infant Care

Surgery

Transplant

Urology

Other (please specify)

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* 15. Advisor Information

Interest areas:

Cancer Patient Support

Clerical

Emergency Department

Inpatient: Visiting patients and providing non-clinical support

Outpatient: Providing non-clinical support services

Patient Mail

Radiology Oncology

Spiritual Care Department

WHY WOULD YOU LIKE TO SERVE AS AN ADVISOR?

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* 16. PLEASE LIST WHEN YOU ARE AVAILABLE TO ATTEND MEETINGS

Daytime

Evening

Weekend

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* 17. I WOULD BE INTETESTED IN HELPING WITH

Reviewing and giving feedback patient and family satisfaction tools.

Developing/reviewing educational materials.

Planning for the hospitalization (inpatient) care experience.

Planning for the design of systems of care and facilities for the surgical experience.

Planning for the clinic (outpatient or ambulatory) care experience.

Educating medical students, residents, new employees, and other staff about the experience of care and effective communication and support.

Participating in facility design planning.

Improving the coordination of care and the transition to home and community care.

Long-term advisory council membership to have impact and influence on policies and practices that affect the care and services patients receive.

PLEASE SHARE ISSUES OF SPECIAL INTEREST

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* 18. IF YOU HAVE SERVED AS AN ADVISOR, AN ACTIVE VOLUNTEER COMMITTEE MEMBER, OR DONE PUBLIC SPEAKING FOR OTHER PROGRAMS OR ORGANIZATIONS, PLEASE BRIEFLY DESCRIBE THIS EXPERIENCE.

Patient and Family Advisory Council Application

Question Title

* 1. FIRST NAME

Question Title

* 2. LAST NAME

Question Title

* 3. STREET ADDRESS

Question Title

* 4. CITY

Question Title

* 5. STATE

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* 6. ZIP CODE

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* 7. HOME PHONE

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* 8. CELL PHONE

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* 9. EMAIL

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* 10. LANGUAGE(S) YOU SPEAK

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* 11. I AM...

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* 12. DATES CARE PROVIDED WITH HONORHEALTH CANCER CARE

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* 13. HAVING ACCESS TO CANCER SUPPORT GROUPS, ONCOLOGY SPECIFIC HEALTH & WELLNESS OR HEALTHY LIFESYLE CLASSES WOULD BE A GOOD OFFERING AND CONTRIBUTOR TO THE CANCER CARE JOURNEY IF OFFERED

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* 14. WITHIN THE LAST TWO YEARS, WHAT HONORHEALTH SERVICES HAVE YOU OR YOUR FAMILY MEMBER USED? *Indicates Cancer Care Services

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* 16. PLEASE LIST WHEN YOU ARE AVAILABLE TO ATTEND MEETINGS

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* 17. I WOULD BE INTETESTED IN HELPING WITH

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* 18. IF YOU HAVE SERVED AS AN ADVISOR, AN ACTIVE VOLUNTEER COMMITTEE MEMBER, OR DONE PUBLIC SPEAKING FOR OTHER PROGRAMS OR ORGANIZATIONS, PLEASE BRIEFLY DESCRIBE THIS EXPERIENCE.

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* 19. WHAT ARE SPECIFIC ACTS THAT HEALTHCARE PROFESSIONALS DID OR SAID THAT WAS MOST HELPFUL TO YOU AND YOUR FAMILY?

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* 20. WHAT ARE SPECIFIC AREAS THAT YOU OR YOUR FAMILY WOULD LIKE HEALTHCARE PROFESSIONALS TO DO DIFFERENTLY IN ORDER TO BE MORE HELPFUL?