AHWM Patient Family Advisory Council Application

Patient Family Advisory Council Questionnaire
Applicant Information
Name*

FirstLast
Email
Phone Number*

Area CodePhone Number
What is your age?*
Preferred language:*

EnglishSpanishMandarin/ChineseOther
What is your primary language?*
What is your gender identity?*

MaleFemaleTrans Female/ Trans WomanTrans Male/ Trans ManGenderqueer or Nonbinary GenderPrefer not to discloseOther
Please tell us about your experience at Adventist Health White Memorial
Have you ever been hospitalized at Adventist Health White Memorial?*

YesNo
How long was your longest hospitalization at Adventist Health White Memorial?*
Have you ever been a caregiver for a patient who has been hospitalized at Adventist Health White Memorial?*

YesNo
How long was the longest hospital stay of the person you were caring for?*
How many times have you or the person in your care been hospitalized at Adventist Health White Memorial in the last three years?*
How would you describe your hospital experience at Adventist Health White Memorial?*
What did the hospital do well during your or your loved one's stay?*
What could the hospital have done better?*
Do you have a provider at a Adventist Health White Memorial Campus clinic?*

YesNo
Provider name:*
Please tell us more about you
What Patient Family Advisory Council are you applying to?*
Why do you want to become a member of the council?*
Do you feel comfortable working in groups, speaking up and providing input?*
Eligibility Criteria
Are you able to attend meetings at Adventist Health White Memorial during weekdays?*

YesNo
Are you able to attend meetings at Adventist Health White Memorial during evenings?*

YesNo
Are you willing to sign an agreement promising not to disclose confidential information given to you in your role as a member of the Patient Family Advisory Council for Adventist Health White Memorial?*

YesNo
I certify that the information given above is complete and accurate and I understand that misrepresentation of information will result in rejection of this application or discharge, (if discovered after participation begins). I understand that I will not be paid for my services as a member of the Patient and Family Advisory Council. I agree to abide by the guidelines of Patient Family Advisory Council, to respect patient confidentiality, and uphold the traditions and standards of Adventist Health White Memorial. I understand that membership on the Patient and Family Advisory Council will be based upon approval from the Patient and Family Advisory Council.
Name*

First NameLast Name
Date*

MonthDayYear
Date
By providing your details and clicking "Submit" you agree to:
- Receive communications from Adventist Health through email, SMS, text, or calls by an automated telephone dialing system for the purpose of Adventist Health maintaining its relationship with you and providing you information related to services you may be interested in.
- Adventist Health collecting and disclosing to third parties personal information and communications for the purpose of fulfilling your inquiries or requests for services or information.
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Patient Family Advisory Council Questionnaire