Thank you for taking the time to complete this enrollment for The Children's Clinic's Patient Family Advisory Council. 


Please provide brief, descriptive answers to the following questions. 

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* 1. What are some of the specific things that health care professionals at The Children's Clinic do/have done to help you or your family? (The health professional can be a nurse, a physician's assistant, a doctor, or someone at the front desk)

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* 2. What are some of the things you would like The Children's Clinic to do differently to better help patients and their families? 

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* 3. Are there certain topics or areas of the clinic in which you have a special interest?

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

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* 5. Please outline one activity that you participated in as a team member- such as a sport, community event, or work-related activity-- and how you view your contribution to achieve effective teamwork.

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* 6. What positive improvements to patient care would you like to see as a result of your participation in the Patient and Family Advisory Council? 

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* 7. Does your child or children have special health needs?

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* 8. If you are selected to be a participant, can you commit to attend one meeting each month? 

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* 9. Are you willing to interview and be interviewed by another council participant? 

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* 10. Are you willing to sign a confidentiality agreement?

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* 11. Please provide your contact information

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* 13. What is your preferred contact method?

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* 14. What is your preferred contact time? (Check all that apply)

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* 15. What is your race?

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* 16. What are the ages of your children

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* 17. What is your gender

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* 18. What pronouns do you use?

0 of 18 answered
 

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