Patient and Family Advisory Council Application

Queensway Carleton Hospital (QCH) has embraced the need for a patient and family centered approach to health care and has prioritized the development of support systems that will allow us to enhance the delivery of health care services around the needs of our patients and families.  The purpose of the Patient and Family Advisory Council is to form collaborative partnerships between patients/families and the QCH leadership team to improve quality of care and the patient experience.  For more information please contact Patient Relations  at 613-721-2000 ext 5655 or patientrelations@qch.on.ca

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* 1. Contact information

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* 2. I am (please check all that apply)

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* 3. When did you or your loved one receive care at Queensway Carleton Hospital?

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* 4. what services did you or your loved one receive at Queensway Carleton Hospital? (please check all that apply)

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* 5. I am interested in participating as a 

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* 6. Why do you want to become a Patient and Family Advisor at Queensway Carleton Hospital 

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* 7. What do you think you could contribute as a Patient and Family Advisor member?

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* 8. Please describe any experience you may have had as a member of a team or committe through work or volunteering in the community:

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* 9. Are you comfortable if we communicate to you (written and verbal) in English?

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