HHHN Patient Advisory Council: Member Interest Form
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1.
Council Overview:
Hudson Headwaters’ Patient Advisory Councils bring together patients and caregivers to share feedback and help improve care across our network. Council members meet with health center leaders twice a year (virtually or in person) to discuss what’s working and where we can improve—from check-in and scheduling to provider visits and services. Members also stay engaged between meetings through occasional surveys or projects. Your perspective can help shape a better experience for all patients. Interested in joining? Please continue the survey below to share more about yourself.
Please type your full name in the box below to confirm you read the overview.
(Required.)
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2.
Mailing Address:
(Required.)
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3.
Phone Number (preferred):
(Required.)
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4.
Email Address (preferred):
(Required.)
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5.
Which Health Center do you visit most frequently?
(Required.)
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6.
Why do you want to join the Patient Advisory Council?
(Required.)
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7.
What relevant skill or talent do
you bring to the Patient Advisory Council? Briefly describe a time in which you demonstrated this skill or talent.
(Required.)
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8.
Have you ever shared suggestions with us before?
(Required.)
No, I have not.
Yes, I have. This is how:
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9.
Are you comfortable signing a confidentiality agreement?
(Required.)
Yes
No
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10.
Council Agreement:
Before sending in your submission, please read and respond to the agreement below.
All patient advisory members are expected to attend the council meetings, which occur twice per year for 60 minutes either virtually via Teams or in-person at a Network building. Members are expected to engage in these meetings respectfully by listening to others, asking questions, sharing concise feedback, offering new and appropriate topics of discussion, suggesting feasible ways in which the Network can improve their patients' experiences, etc. Additionally, members are expected to participate in initiatives and discussions between meetings. Finally, all members are expected to serve on the council for at least
one year
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Do you agree to uphold these expectations if selected to participate as a member of the PAC?
(Required.)
Yes
No
