*1.Address(Required.)

Name *

Company

Address *

Address 2

City/Town *

Province *

Postal Code *

Country *

Email Address *

Phone Number *

*2.In the past 3 years have you or your family used the services of Lennox and Addington County General Hospital?(Required.)

Yes

No

*3.Why would you like to serve as a member of PFAC?(Required.)

*4.What are some issues of special interest to you?(Required.)

*5.What skills and/or experience do you have that would make you an effective PFAC member?(Required.)

*6.Some hospital meetings take place at 7A.M. or 7P.M.  Most happen somewhere in between.  Please specify the times when you are able to attend meetings:(Required.)

Daytime

Evenings

*7.Please specify your hours of availability to attend meetings.(Required.)

*8.I would be interested in helping with: (you may check more than one box)(Required.)

Reviewing patient Satisfaction Surveys

Developing/Reviewing patient/family educatinal materials and website resources

Planning for the out-patient experience

Planning for the inpatient care experience

Planning for the emergency care experience

Ensuring patient safety and the prevention of medical errors

Education medical students and residents, new employees and other staff about the experience of care and effectie communication and support

Improving the coordination of care, discharge planning and the transition to home and community care

Developing the uses for information technology, including electronic medical records

Medicine/Critical Care

Surgery

Diagnostic Imaging

Convalescent Care/Long Term Care

Other (please specify)

*9.Please read carefully and check before Submitting:

Personal information contained on this form is collected pursuant to the Public Hospitals Act and the Freedom of Information and Protection of Privacy Act (FIPPA), and will be used for the purpose of patient and PFAC Member selection at LACGH. We will not share this information otherwise without permission from the applicant.

LACGH reserves the right to accept or not accept patient and family advisor applicants. Patient and family advisors are selected according to their interest, skills, suitability, and the needs of the hospital. LACGH reserves the right to release a member of PFAC from his/her/their position if, in the opinion of the hospital, continuance of the PFAC member role could cause a detriment to the hospital.
(Required.)

I understand that submitting this application and/or being interviewed does not guarantee a position as a member of PFAC.

I understand that prior to beginning as a PFAC member I must sign a confidentiality agreement.

I give permission for LACGH to discuss my application with references listed below.

*10.Please provide the names and contact information of two references who are not related to you.
Applicants who are selected for an interview will normally be contacted within 30 days of submission of the application form.(Required.)

Reference 1:

Reference 2: