Personal Information

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* 1. Personal Information

Language(s) you speak:

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* 2. Language(s) you speak:

Have you or a family member ever been employed in healthcare?

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* 3. Have you or a family member ever been employed in healthcare?

Are you a:

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* 4. Are you a:

How did you hear about the Patient and Family Advisory Council?

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* 5. How did you hear about the Patient and Family Advisory Council?

Please choose times when you are available to attend meetings (check all that apply):

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* 6. Please choose times when you are available to attend meetings (check all that apply):

Within the last 12 months have you been a:

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* 7. Within the last 12 months have you been a:

Your care provided at RAMC was primarily (check all that apply):

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* 8. Your care provided at RAMC was primarily (check all that apply):

We believe our patient and family advisory partners should reflect the diversity of patients, families and friends who use our medical center. In light of this, please share some demographic information about yourself (optional):

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* 9. We believe our patient and family advisory partners should reflect the diversity of patients, families and friends who use our medical center. In light of this, please share some demographic information about yourself (optional):

What is your gender?

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* 10. What is your gender?

Which race/ethnicity best describes you? (Please choose only one.)

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* 11. Which race/ethnicity best describes you? (Please choose only one.)

Why would you like to be on the Reedsburg Area Medical Center Patient and Family Advisory Council?

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* 12. Why would you like to be on the Reedsburg Area Medical Center Patient and Family Advisory Council?

What special interest or experiences do you have to offer to the Council?

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* 13. What special interest or experiences do you have to offer to the Council?

Please note any questions or concerns:

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* 14. Please note any questions or concerns:

I understand that (checking all 4 boxes below indicates your agreement):

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* 15. I understand that (checking all 4 boxes below indicates your agreement):

Please type your name for your electronic signature:

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* 16. Please type your name for your electronic signature:

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