Patient Experience Advisory Committee Survey

Health for All Family Health Team is looking for patients to join our Patient Experience Advisory Committee! Members will help improve the quality of care we provide to our patients and the quality of our services. If you are interested in this opportunity, please complete the form below. It will take approximately 5-10 minutes to complete.

Please note: The questions in this form will help ensure that you are a good fit for the role. In this form we will ask some personal details because we want to include members on the committee with different life experiences and backgrounds. Our team will keep this information confidential. If you have questions about the process, please email communications@healthforallfht.ca

Please tell us about yourself:

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* 1. Full Name:

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* 2. Email:

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* 3. Phone number:

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* 4. Name of my healthcare provider:

Please tell us about your background:

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* 5. The gender you identify with is:

Woman

Man

Transgender woman

Transgender man

Non-binary

Prefer not to answer

Other (please specify)

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* 6. The highest education I completed:

Grade school

High school

College/university degree

Post-graduate degree (i.e. Masters, PHD)

Prefer not to answer

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* 7. I would describe myself as:

Black (ex. African, Afro-Caribbean, African-Canadian descent)

East/Southeast Asian (ex. Chinese, Korean, , Japanese, Taiwanese descent; Filipino, Vietnamese, Cambodian, Thai, Indonesian)

Indigenous (ex. First Nations, Metis, Inuk/Inuit)

Latino (ex. Latin American, Hispanic descent)

Middle Eastern (ex. Afghan, Egyptian, Iranian, Lebanese, Turkish, Kurdish, Arab, Persian, West Asian descent)

South Asian (ex. East Indian, Pakistani, Bangladeshi, Sri Lankan, Indo-Caribbean)

White (European descent)

Prefer not to answer

Other (please specify)

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* 8. I have a disability:

By disability we mean something that limits your senses, physical or mental abilities on a long-term basis (for example your ability to see, hear, speak, move, learn, remember or concentrate)

Yes

Prefer not to answer

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* 9. Why would you like to be a member of our Patient Experience Advisory Committee?

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* 10. If you are chosen as one of the successful candidates, what is your preferred time to attend committee meetings ?

Afternoons (between 2:00 PM-4:00 PM)

Evenings (between 5:00 PM-7:00 PM)

Patient Experience Advisory Committee Survey

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* 1. Full Name:

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* 2. Email:

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* 3. Phone number:

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* 4. Name of my healthcare provider:

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* 5. The gender you identify with is:

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* 6. The highest education I completed:

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* 7. I would describe myself as:

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* 8. I have a disability:By disability we mean something that limits your senses, physical or mental abilities on a long-term basis (for example your ability to see, hear, speak, move, learn, remember or concentrate)

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* 9. Why would you like to be a member of our Patient Experience Advisory Committee?

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* 10. If you are chosen as one of the successful candidates, what is your preferred time to attend committee meetings ?

* 8. I have a disability:

By disability we mean something that limits your senses, physical or mental abilities on a long-term basis (for example your ability to see, hear, speak, move, learn, remember or concentrate)