1.Personal Information:

Name

Address

Address 2

City/Town

State/Province

ZIP/Postal Code

Email Address

Phone Number

2.What is your experience with Infinity Health

I am a patient (current or former)

I am a patient’s family member/support person

3.The date of your Infinity Health patient experience was:

Less than 6 months ago

6 months to one year ago

1-5 years ago

Greater than 5 years ago

4.The care received at Infinity Health was provided by:

Behavioral Health Services

Dental Health Services

Pharmacy

Medical Clinic

Other (please specify)

5.How did you hear about this opportunity?

From the Infinity Health website

Information was given to me by an Infinity Health employee

PFAC brochure from Infinity Health

I was invited to apply by a Infinity Health employee

Other (please specify)

6.Please tell us about your experience with our health center. What impressed you? Where could we improve?

7.Please share any previous experiences you have had serving on a board or organizational committee (work, community, church, etc.):

8.What interests you the most about the possibility of serving on the Patient Family Advisory Council?

9.Please provide a brief description of what talents or strengths you would bring to the advisory council.

10.Would you be able to commit to attending 6-8 meetings per year at Infinity Health?

Yes, absolutely.

I would definitely do my best to attend them all.

I could probably only commit to 1 or 2.

11.Are you a current/previous employee of Infinity Health?

Current employee of Infinity Health

Current Infinity Health board member

Previous Infinity Health employee, but no longer employed there

Previous board member

None of the above