External Embed

*First Name

*Last Name

*Address

*City

*State

*Zip

*Home Phone

Cell Phone

*Best # to reach you

Home

Mobile

*Email

*Best way to reach you

Phone

Email

Members of the Patient and Family Advisory Council reflect a wide range of experience, age, gender, background, ethnicity, culture, beliefs and more. Please answer the following questions regarding your experience(s) with RWJBarnabas Health.

*Age

*I am or have been

*Relationship to patient

*Within the past six months, where have you or your family member(s) been treated? (Check all that apply)

Inpatient Units	Outpatient Services
Emergency Services	Other

*Other

*Please tell us why you are interested in serving as a patient/family advisor and why you feel you would be a good representative for other patients/families.

*Please describe any other committee experience you have had either in the community, schools, churches, etc.?

*We believe that the PFAC should reflect the cultural diversity of our patients and families. Please describe any diversity you have (ethnic, gender, racial, disability)

*Are you comfortable speaking in front of other people, either presenting information or sharing personal experiences?

Yes

No

*Please explain

*Would you be able to make a commitment of at least two year?

Yes

No

*How long could you commit?

*Best day(s) for meetings:

Mondays	Tuesdays	Wednesdays
Thursdays	Fridays

*Best time(s) for meetings:

Mornings (9 AM-12 PM)

Afternoons (12 PM-4 PM)

Evenings (4 PM-7 PM)

APPLICANT ACKNOWLEDGEMENT & SIGNATURE

I acknowledge that I have provided accurate information to the best of my ability.

*Signature

Notes: Members must sign a confidentiality statement. Members must also go through the volunteer orientation process.

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