Patient/Family Advisory Council Application

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* 1. Have you or a family member received care at Valley View Hospital in the last two years?

Yes, I am/have been a patient

Yes, I am/have been a family member of a patient

Other

No

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* 2. If yes, where have you received care?

Hospital Inpatient Unit (Acute Care, Critical Care, Family Birthplace)

Emergency Department

Urgent Care

Outpatient Services (Lab, Radiology, etc.)

Surgical Services

Other

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* 3. Please tell us a little bit about yourself including any life experiences that would influence your contributions as a council member.

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* 4. Why would you like to be a member of the Patient/Family Advisory Council?

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* 5. What are some specific things that health care professionals did or said that were most helpful to you and your family during any of your experiences with us?

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* 6. What are some specific things that you or your family member might like to see changed in our organization?

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* 7. What is your contact information? Please list your name, address, email, and phone number.

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* 8. Should you become a member of Valley View Hospital's Patient/Family Advisory Council, will you allow us to share your contact information with other PFAC members?

Yes, I will allow my contact information to be shared with other PFAC members.

No, I do not wish to have my contact information shared with other PFAC members.