Call to Join the Nipissing Wellness Ontario Health Team’s Nipissing Wellness Patient and Family Collaborative Network

Your Expression of Interest to Join the Nipissing Wellness Patient and Family Collaborative Network

The Nipissing Wellness Ontario Health Team (OHT) is seeking individuals to participate on the Patient and Family Collaborative Network to help co-design a new model of health system integration with enhanced programs and service delivery.

We are looking for Patients/clients, caregivers/family who live in the Nipissing Area and have:

lived experience with the health care system and
who are willing to passionately share their stories, insights, and
have ideas to help inform system changes and improve care delivery.

Note: Members shall be members of the public. Because elected representatives, practicing healthcare professionals, paid employees of health charities, employees of companies in health industries, elected officials, and employees of provincial and federal health ministries and agencies already have a voice in making their opinions known to decision makers, they are not eligible for membership.

Your “application” to sit on the Collaborative Network will be carefully reviewed by members of the Nipissing Wellness OHT. Membership will be selected to ensure diversity that is reflective of the area’s population, in relation to age, geographic distribution, cultural diversity, socio-economic status and experience with the health system. To view the terms of reference, click here.

Shortlisted candidates will be interviewed to determine suitability and commitment.

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* 1. Contact information

First and Last Name:

Address (including postal code):

Email:

Home phone #:

Work phone #:

Cell phone #:

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* 2. What is the best way to contact you?

Phone

Mail

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* 3. What is the best time to contact you?

Days

Evenings

Weekends

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* 4. Do you have any physical limitations or special needs?

Yes. Please specify:

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* 5. Please tell us if you identify with any of the following:

	Yes	No
First Nations	First Nations Yes	First Nations No
Métis	Métis Yes	Métis No
Inuit	Inuit Yes	Inuit No
Francophone	Francophone Yes	Francophone No
English	English Yes	English No
Chinese	Chinese Yes	Chinese No
Italian	Italian Yes	Italian No

Other

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* 6. How did you hear about the opportunity to participate in the Nipissing Wellness Patient and Family Collaborative Network?

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* 7. Which part(s) of the health care system do you have experience with? Please check off all that apply.

Home and Community Care ( i.e. Red Cross, Meals on Wheels, ICAN, in-home nursing or PSW care)

Community Health Centre

Community Mental Health Agency

Primary Care

Family Health Team

Hospice Palliative Care

Hospital

Long-Term Care Home

First Nations Health Care/ Health Centre

Other (Please Describe):

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* 8. Without sharing any personal health information, briefly describe your experience with the health care system and what unique perspective you would bring to the PFAC.

Home and Community Care ( i.e. Red Cross, Meals on Wheels, ICAN, in-home nursing or PSW care)

Community Health Centre

Community Mental Health Agency

Primary Care

Family Health Team

Hospice Palliative Care

Hospital

Long-Term Care Home

First Nations Health Care/ Health Centre

Other (Please Describe):

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* 9. In support of your application, please provide your input into any of the following areas:

Are you currently, or have you ever been, a member of a patient advisory committee? Please outline where and when.

What other committees, if any, have you/do you participate in?

Are you able to commit to meeting monthly and more frequently as required?

Would you be interested in a 2 year term of 3 year term on the Near North Health and Wellness OHT PFAC?

What do you see as the top three health care priorities in Nipissing-East Parry Sound area?

Why are you interested in becoming a member of the Near North Health and Wellness OHT PFAC?

Please describe your approaches (if any) to date, to improve the local health care system.

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* 10. Please provide any other comments that would support your expression of interest for membership on the Near North Health and Wellness OHT PFAC.

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* 11. Please check to indicate that you have read the Terms of Reference and
understand the role of the Nipissing Wellness Patient and Family Collaborative Network and its members.

I understand

If you have any questions, please contact co-chairs Tammy Adjoudj and Theresa Tasse at NWPFCN@nipissingwellness.ca

*We thank you for your interest and taking the time to complete this application. All applicants will be contacted as to the status of their application.

All information contained on this form is considered confidential and is intended for use only for the Nipissing Wellness Patient and Family Collaborative Network. You may be contacted to participate in an interview. All applicants submitted will be kept on file; however applications will only be reviewed when there are committee vacancies.

100% of survey complete.

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* 1. Contact information

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* 2. What is the best way to contact you?

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* 3. What is the best time to contact you?

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* 4. Do you have any physical limitations or special needs?

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* 5. Please tell us if you identify with any of the following:

Question Title

* 6. How did you hear about the opportunity to participate in the Nipissing Wellness Patient and Family Collaborative Network?

Question Title

* 7. Which part(s) of the health care system do you have experience with? Please check off all that apply.

Question Title

* 8. Without sharing any personal health information, briefly describe your experience with the health care system and what unique perspective you would bring to the PFAC.

Question Title

* 9. In support of your application, please provide your input into any of the following areas:

Question Title

* 10. Please provide any other comments that would support your expression of interest for membership on the Near North Health and Wellness OHT PFAC.

Question Title

* 11. Please check to indicate that you have read the Terms of Reference and understand the role of the Nipissing Wellness Patient and Family Collaborative Network and its members.

* 11. Please check to indicate that you have read the Terms of Reference and
understand the role of the Nipissing Wellness Patient and Family Collaborative Network and its members.