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Community Council Expression of Interest Survey
1.
Do you currently work within the healthcare system or are a board member within the healthcare system?
Yes
No
2.
Which of the following perspectives do you bring?
Patient/Client with lived experience
Resident/Interested Member of the Public
Family or Caregiver
3.
What parts of the health care system have you, or the person you care for, experienced within the last 3 years? Choose all that apply.
Primary Care
Home Care
Long Term Care
Home and Community Care
Community Support Services
Mental Health and Addictions
Palliative Care
Paramedic Services or Community Paramedicine
Aboriginal Health Services
Chronic Disease Programs and Services
Rehabilitative Care Services
4.
Why do you want to join the Grey Bruce OHT Community Council?
5.
What do you hope to contribute? Please feel free to share examples of your skills and/or experience?
6.
Is there anything else you want to share about yourself? Please do not include any personal health information.
7.
Do you have any existing or previous experience providing input as a Patient, Client, Resident, Family, or Caregiver Advisor for any other health care organization?
8.
Please list the organizations or groups you were part of. Please also list any projects, policies, or programs you provided input on.
9.
Where do you reside?
10.
What pronouns do you ascribe to?
11.
What is your age range:
16-35
36-55
56-64
65-79
80+
12.
Do you identify as being a part of any equity deserving groups? (Equity-deserving individuals and groups are those who face barriers to equal access, opportunities and resources due to disadvantage and discrimination created by institutions, systems, narratives and individuals in power. Some examples are Indigenous, Black, mixed race, people of colour; immigrants and refugees; 2SLGBTQIA+; living with disability; not supported with a living wage or living under the poverty line; intersectional oppression ex. Anti-muslim, racism, sexism, classism) The Grey Bruce OHT is actively seeking the input from a variety of voices across Grey and Bruce County. The answers to this question will help us understand if we were able to reach marginalized/equity-seeking individuals in our recruitment.
Yes
No
Prefer not to answer
13.
Do you have time to commit to attending virtual or in person monthly meetings that last about an hour?
Yes
No
14.
Would you require transportation assistance for in person meetings?
Yes
No
15.
Contact Information
Name
Email Address
Phone Number
