Patient and Family Advisory Application Form

Harrow Health Centre Family Health Team (HHC) must be able to leave messages pertaining to the PFAFG’s efforts and freely provide any information regarding HHC’s PFAFG meeting. Please ensure contact details are private.

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* 1. Full Name:

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* 2. Address:

Name

Address

Address 2

City/Town

State/Province

ZIP/Postal Code

Country

Email Address

Phone Number

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* 3. Have you been a patient (or a family member of a patient) at the HHC in the past 5 years?

Yes

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* 4. Are you able to attend a 2-3 hour meeting once a year?

Yes

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* 5. Can we contact you, and send all materials pertaining to the PFAFG, via email?

Yes

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* 6. Would you be willing to participate in follow up interview?

Yes

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* 7. Are you able to share your experiences in ways that other can learn from?

Yes

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* 8. Do you have a personal email address that we can reach you at privately?

Yes

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* 9. Are you comfortable using the Zoom platform?

Yes

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* 10. Why would you like to serve as an advisor?

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* 11. Do you have any gifts or talents that would be advantageous to this group?

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* 12. Using the following scale, how would you rate your…

	Poor	Fair	Good	Very Good	Excellent
Collaborative skills	Collaborative skills Poor	Collaborative skills Fair	Collaborative skills Good	Collaborative skills Very Good	Collaborative skills Excellent
Comfort speaking in a group setting	Comfort speaking in a group setting Poor	Comfort speaking in a group setting Fair	Comfort speaking in a group setting Good	Comfort speaking in a group setting Very Good	Comfort speaking in a group setting Excellent
Listening skills	Listening skills Poor	Listening skills Fair	Listening skills Good	Listening skills Very Good	Listening skills Excellent
Ability to understand views of others	Ability to understand views of others Poor	Ability to understand views of others Fair	Ability to understand views of others Good	Ability to understand views of others Very Good	Ability to understand views of others Excellent
Ability to express thoughts and ideas	Ability to express thoughts and ideas Poor	Ability to express thoughts and ideas Fair	Ability to express thoughts and ideas Good	Ability to express thoughts and ideas Very Good	Ability to express thoughts and ideas Excellent

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* 13. Please specify the hours you can attend meetings (may be virtual or in-person):

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* 14. Please provide the names, telephone numbers and email addresses of two references who are not related to you:

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* 15. Personal information contained on this form is collected pursuant to the Personal Health Information Protection Act (PHIPA) and will be used for the purpose of Patient and Family Advisor selection and placement at HHC. We will not use this information otherwise without permission from the applicant.

HHC reserved the right to accept or not accept advisor applicants. Patient and family advisors are selected according to their interest, skills, suitability, and the needs of the Family Health Team. HHC reserves the right to release a patient and family advisor from his/her position if, in the opinion of the HHC, continuance of the advisor could cause a detriment to the work of the PFAFG and/or the HHC.

By submitting this application, I have read and understand (please checkmark the boxes):

I understand that submitting this application does not guarantee a position as a patient and family advisor.

I understand upon acceptance as a patient and family advisor, I will be required to complete an advisor orientation.

I understand that prior to beginning in my advisor role, I must sign a confidentiality agreement and a code of conduct agreement.

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* 16. CONFIDENTIALITY AGREEMENT

BACKGROUND:

The advisor may be exposed to events involving patients of the HHC.
The advisor may be exposed to information that is considered confidential by the policies of the HHC

IN CONSIDERATION OF, and as a condition of the review of the HHC, the advisor Confidential Information in addition to other valuable consideration, the receipt and sufficiency of which consideration is hereby acknowledged, the parties to this Agreement agree as follows:

CONFIDENTIAL OBLIGATIONS:

                     I.            The advisor acknowledges their obligation to maintain Patient Confidentiality.

                   II.            Except where otherwise indicated and provided, the advisor must keep the Confidential Information confidential.

                  III.            Except where otherwise indicated and provided, the Confidential Information will remain the exclusive property of the HHC or the Patient on request.

                 IV.            The confidential Information will only be used by the advisor for the Permitted Purpose.

                   V.            The advisor will not use the Confidential Information for any purpose which might be directly or indirectly detrimental to the HHC, the Patient, or any of their affiliates or subsidiaries

The obligations and requirements to protect the CONFIDENTIAL INFORMATION imposed on the advisor in this Agreement and any obligations to provide notice under this Agreement will survive the expiration or termination, as the case may be, of this Agreement.

I hereby acknowledge and confirm reading this confidentiality agreement and I agree to abide by its terms at all times.

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* 17. CODE OF CONDUCT

PURPOSE:

The Harrow Health Centre Family Health Team (the “HHC”) is committed to ensuring that in all aspects of its affairs it maintains the highest standards of public trust and integrity.

POLICY STATEMENTS:

This Code of Conduct applies to all advisors.

PROCEDURE:

Respectful Conduct

It is recognized that advisors bring diverse backgrounds, skills, and experiences to the focus group. Advisors will not always agree with one another on all matters. All debates shall take place in an atmosphere of mutual respect, collegiality, and courtesy. The authority of the facilitator must be respected at all times wherever the focus group convenes by all advisors. The PFAFG will be conducted within the best interests of the HHC and as such for the purpose of these meetings, the facilitator will be designated as the Executive Director.

I hereby acknowledge and confirm reading this conflict policy and I agree to abide by its terms at all times.