Patient and Family Advisory Board Enrollment Survey

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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?

Yes

If yes, please give a brief description/ or diagnosis

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

Yes

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

Yes

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

Yes

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* 11. Please provide your contact information

Name

Address

Address 2

City/Town

State/Province

ZIP/Postal Code

Email Address

Phone Number

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* 12. Who is your Primary Care Provider at The Children's Clinic?

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* 13. What is your preferred contact method?

Phone

Mail

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

M-F Mornings

M-F Afternoons

M-F evenings

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* 15. What is your race?

White

Hispanic/Latino

Black/African American

Asian

American Indian or Alaska Native

Native Hawaiian or Other Pacific Islander

Other

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* 16. What are the ages of your children

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* 17. What is your gender

Male

Female

Female-to-Male

Male-to-Female

Nonbinary

Other (please specify)

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* 18. What pronouns do you use?

She/Her

He/Him

They/Them

Something else (Please specify)