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Woodstock Hospital Patient & Family Advisory Program
THANK YOU FOR YOUR INTEREST IN JOINING! We value your involvement.
All information you share will be kept secure and only used for the purposes of the Program.
OK
1.
What is your name (first, last)?
2.
What is your email address?
3.
What is your phone number?
4.
I identify as:
a patient who has received (is receiving) care at Woodstock Hospital
a family member of a patient who has received (is receiving) care at Woodstock Hospital
a caregiver of a loved one who received care at Woodstock Hospital
an interested member of the community
5.
My most recent experience at Woodstock Hospital was with:
Acute Medicine
Ambulatory Care Services
Cardio Respiratory
Chemotherapy Clinic
Complex Care
Critical Care Unit
Diagnostic Imaging
Dialysis
Emergency Department
Inpatient Rehabilitation
Inpatient Rehabilitation Outpatient Program
Maternal Child and Women's Health Services
Mental Health
Occupational Therapy
Physiotherapy
Recreation Therapy
Speech Language Pathology
Surgical Services
Urology
Woodstock Rehabilitation Clinic
Other (please specify)
6.
I have experience with:
participating in focus groups or discussion groups
sitting on committees
sitting on boards
sharing my story
other (please specify)
7.
I have an interest in (in order of time commitment):
sharing feedback by email (or phone) (less than 1 hour per month)
participating in online meetings/discussions (1-2 hours per month)
sitting on a hospital committee (2-3 hours per month)
sitting on the Patient and Family Advisory Council (3-4 hours per month, 2 year commitment)
8.
Do you have any work/life experience that may be useful in your role? For example a background in education, community involvement, health care, finance, business/management, etc. Please share below:
9.
Please provide a short description of what you hope to contribute as a patient and family advisor (please do not include any personal health information):
Current Progress,
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