Thank you for your interest in volunteering at MetroHealth.

Patient Family Advisory Council Application

18 years of age or older

* Application Date

Personal Information

* Name prefix

* First Name

MI

* Last Name

* Florida Address only; no P.O. Box

* City

* State

* Zip Code

Residential Status

* Preferred Phone Number (Include area code and dashes)

Phone Type

* Email Address

Are you over the age of 18?

Referral Method

How did you hear about the Patient Family Advisory Council?

If applicable, who were you referred by?

Emergency Contact

Who would you like us to contact in the event of an emergency?

* Emergency Contact Name

* Relationship

* Phone Number (Include area code and dashes)

Education

* Tell us about your education and/or professional experience.

Are you currently enrolled in a college/trade school?

College Degree:

AA/AS

BA/BS

MA/MS

PhD

Degree in progress

Other

* Major and/or Minor

Work Experience

* Occupation/Former Occupation

* Employer/Former Employer

Are you currently employed?

Yes

No

Personal/Professional Skills

Computer Skills

* Are you proficient in any computer programs?

List Languages Spoken

Skills (Select all that apply)

Please share any other personal/professional skills:

Getting to Know You

Have you or one of your family members been a patient at one of the NCH Healthcare System hospitals within the last two years?

Yes

No

* What was the approximate duration of stay?

* If a family member, what is the relationship to the patient?

What department or unit did you or your family member stay on? (Select all that apply)

* Why are you interested in joining the Patient Family Advisory Council?

Do you currently serve on any committees or board of directors?

Yes

No

If yes, which ones and in what capacity?

The Patient Family Advisory Council will meet no more than ten times per year. Are you able to attend 80% (8 meetings) per year?

Yes

No

What strengths and/or talents would you like to offer the Patient Family Advisory Council?

As needed, our NCH Patient Family Advisory Council members serve on miscellaneous committees. These committees are formed to expedite hospital functions such as policies, billing, discharge planning, inpatient experience, etc. Please state any committee preference(s).

Are you or an immediate family member being compensated in any way by NCH (pharmaceutical company, medical device

Yes

No

If yes, please explain the nature of the relationship and the vendor.

Background Information

Have you ever been employed by NCH Healthcare System or any of its affiliates?

Yes

No

NCH employment application in progress

If yes, include date hired and department(s).

Check yes if other than a mideameanor traffic violation, you have ever been charged with or convicted for a crime.

Yes

If yes, explain and provide the location (county and state).

Check yes if you have been charged with an unresolved criminal charge. (Are you charged with a crime that has not yet resulted in a plea of guilty, court trial, deferred adjudication or dropping of the charge?)

Yes

If yes, explain and provide the location (county and state).

Check yes if you are currently on probation.

Yes

If yes, explain and provide the location (county and state).

The NCH Healthcare System conducts criminal record checks on all incoming members of the Patient Family Advisory Council. This is done in accordance with the law and in an effort to enhance patient safety. Falsification or failure to disclose complete information will disqualify you from service. A conviction does not necessarily disqualify you from service.

I certify that the information given above is complete and accurate and I understand that misrepresentations and/or withholding of information will result in termination of this application or discharge (if discovered after acceptance).

I understand that I will not be paid for my services as a member of NCH Patient and Family Advisory Council.

I agree to abide by the guidelines of the NCH Patient and Family Advisory Council, to respect confidentiality, and to uphold the standards of NCH Healthcare System. I understand that membership to the NCH Patient and Family Advisory Council will be based on a preliminary interview, panel interview and final approval by the Council.

* I agree

* Enter your full name as your electronic signature here.

* Date

Thank you! We will be contacting you to schedule an interview.

We look forward to meeting you!