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Patient and Family Advisory Council Application
1.
FIRST NAME
2.
LAST NAME
3.
STREET ADDRESS
4.
CITY
5.
STATE
6.
ZIP CODE
7.
HOME PHONE
8.
CELL PHONE
9.
EMAIL
10.
LANGUAGE(S) YOU SPEAK
11.
I AM...
A Patient
A Family Member of a Patient
12.
DATES CARE PROVIDED WITH HONORHEALTH CANCER CARE
2022 to present
2020 to present
2018 to 2020
Earlier than 2018
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
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)
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?
16.
PLEASE LIST WHEN YOU ARE AVAILABLE TO ATTEND MEETINGS
Daytime
Evening
Weekend
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
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.
19.
WHAT ARE SPECIFIC ACTS THAT HEALTHCARE PROFESSIONALS DID OR SAID THAT WAS MOST HELPFUL TO YOU AND YOUR FAMILY?
20.
WHAT ARE SPECIFIC AREAS THAT YOU OR YOUR FAMILY WOULD LIKE HEALTHCARE PROFESSIONALS TO DO DIFFERENTLY IN ORDER TO BE MORE HELPFUL?
