Patient Advisory Collaborative (PAC)

Application

The North York Family Health Team would like to thank you for your interest in our Patient Advisory Collaborative (PAC). This advisory collaborative will help improve and enhance patient experiences at the NYFHT.

By submitting this application, you are agreeing to share your contact information with the NYFHT administrative staff and other members of the PAC. This information will not otherwise be shared without your permission.

Please note, we cannot guarantee that every applicant will be selected to be a participant of the Patient Advisory Collaborative.

Thank you for your interest in supporting the North York Family Health Team in this advisory role.

Demographics

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* 1. Your First and Last Name:

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* 2. Best phone number to reach you:

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* 3. Email address:

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* 4. I am a: (choose all that apply)

Patient

Family Member

Caregiver

Community Member

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* 5. How long have you been a patient of the North York Family Health Team?

Less than one year

1-5 years

6-10 years

More than 10 years

I'm not currently a patient of the North York Family Health Team

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* 6. Please select the age range that applies to you

18-25

26-35

36-45

46-55

56-65

66-75

Over 75

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* 7. Highest level of education completed

Elementary School

High School

College

University

Other (Please specify)

Language:

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* 8. Primary Language:

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* 9. Other Languages (Please list below):

Interest in PAC

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* 10. How do you feel you could support the NYFHT in improving patient care?

Assist in developing/evaluating new NYFHT programs and services by bringing patient and family perspectives

Provide input into developing/evaluating patient education materials

Assist in improving the quality of the health services provided

Participate in developing patient experience and engagement strategies and/or activities

Provide input into strategic planning

Other (please specify)

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* 11. Please indicate your meeting availability, choose all that apply:

Mornings

Afternoons

Evenings

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* 12. Have you been involved in a Patient Advisory Committee previously?

Yes

Patient Advisory Collaborative (PAC)

Application

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* 1. Your First and Last Name:

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* 2. Best phone number to reach you:

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* 3. Email address:

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* 4. I am a: (choose all that apply)

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* 5. How long have you been a patient of the North York Family Health Team?

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* 6. Please select the age range that applies to you

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* 7. Highest level of education completed

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* 8. Primary Language:

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* 9. Other Languages (Please list below):

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* 10. How do you feel you could support the NYFHT in improving patient care?

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* 11. Please indicate your meeting availability, choose all that apply:

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* 12. Have you been involved in a Patient Advisory Committee previously?

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* 13. Do you participate in any other community activities? Please list and describe

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* 14. Use the space below to write anything else about yourself that you would like us to know