AHLM Community Advisory Committee Application

Applicant Information

Name*

FirstLast

Email

Phone Number*

Area CodePhone Number

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry

Please tell us about your experience at Adventist Health Lodi Memorial

Have you ever been hospitalized at Adventist Health Lodi Memorial for more than 24 hours?*

YesNo

How long was your longest hospitalization at Adventist Health Lodi Memorial?*

Have you ever been a caregiver for a patient who has been hospitalized at Adventist Health Lodi Memorial for more that 24 hours?*

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 Lodi Memorial in the last three years?*

How would you describe your hospital experience at Adventist Health Lodi Memorial?*

What did the hospital do well during your or your loved one's stay?*

What could the hospital have done better?*

Please tell us more about you

Do you volunteer in your community? If so, for which organizations?*

Do you feel comfortable working in groups, speaking up and providing input?*

Eligibility Criteria

Is English your first language?*

YesNo

What is your primary language?*

Are you able to attend meetings at Adventist Health Lodi Memorial during weekdays?*

YesNo

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

YesNo

Are you willing to take the necessary immunizations to serve on the Patient Family Advisory Council for Adventist Health Lodi Memorial?*

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 Lodi Memorial?*

YesNo

Are you willing to undergo a background check?*

YesNo

Community Advisory Council Questionnaire

Please tell us more about you