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Patient and Family Advisor Application Form

Thank you for your interest in becoming a Patient and Family Advisor (PFA) at Health Sciences North (HSN). Although PFAs do not have direct contact with patients, their role is vital to HSN as their opinions, ideas and input help influence change and have an impact on the care and services we provide to our patients and families. 
 
Selection of PFAs will be based upon the following criteria:
  • Have had both positive and negative perceptions of their hospital experience.
  • Reflect the diversity of those served by the hospital
  • Is not employed directly by HSN
*Only selected applicants will be contacted for an interview.
Last Name
First Name
Email address
Primary phone number?
Preferred method of communication?
Mailing Address
In the past 2 years, have you or a family member accessed services of Health Sciences North?
How did you hear about the Patient and Family Advisory Program?
Do you consider yourself to be....
How do you describe your gender identity? (check all that apply)
Current status that best describes you (please check one)
Why would you like to serve as a patient or family advisor?
What are some areas of special interest to you?
I would be interested in helping with:
Do you have any skills that would be advantageous to HSN
Please read and check before sending the application:
Please provide the name of a person not related to you who will provide a character reference for you

1. Reference
2. Reference
Applicants who are selected for an interview will normally be contacted within 30 days of submission of the application form.
All information contained on this form is considered confidential and is intended for use by Health Sciences North's Patient and Family Advisor Liaison only. You may be contacted upon receipt of this application form to participate in a face-to-face interview.

If you have any questions please email them to: pfaprogram@hsnsudbury.ca

Thank you for your interest in becoming a Patient and Family Advisor.