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Patient and Family Advisory Council Application

About You

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1. Contact Information

Name:

Company if applicable:

Address:

City/Town:

State:

ZIP:

Phone Number:

Alternate Phone (cell)

Email Address:

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2. Are you presently employed?

Yes

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3. If so, what is your occupation?

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4. Please specify the times that you are available to attend council meetings (check all that apply).

Daytime (8:30 am – 5:00 pm) M-F

Evening (5:00 pm – 8:00 pm) M-F

Weekends (Sat/Sun)

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5. Race (optional)

Asian

Black/African American

Caucasian

Hispanic/Latino

Other, specify (optional)

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6. Age (optional)

18-30

31-40

41-60

61-80

Over 81

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7. Primary language that you speak.

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8. List any other languages that you speak.

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9. The term limits are for one year with an opportunity to be reinstated, if appropriate, for up to three terms. How many years are you able to commit?

One Year

Two Years

Three Years

Comments:

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10. We believe the PFAC should reflect the diversity of patients, families and friends who use our health care services. In light of this, please share anything about yourself that you think would add to the diversity of our council. You might consider your diversity to be ethnic, racial, spiritual, social, economic, gender, disability related, etc.

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11. Why are you interested in becoming a member of the Patient and Family Advisory Council? Please be as specific as possible.

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12. What area(s) of interest would you like to see the Patient and Family Advisory Council address?

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13. What can you contribute to the Patient Family Advisory Council?

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14. Do you now, or have you ever worked for North Shore-LIJ Health System as an employee, volunteer or medical staff member?

Yes

If yes, please list the position, department and dates

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15. Council members are often asked for advice from different departments and units within the hospital. From the list below, please select those departments or units that you are familiar with and could comment on.

Behavioral Health

Billing

Cancer

Cardiology

Dietary/Food Services

Emergency Department

Geriatrics

Housekeeping

Imaging/Radiology

Laboratory

Pediatrics

Neurosciences

Surgery

Urology

Women's Health

Other (please specify)

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16. Have you or a family member used a facility of the North Shore-LIJ Health System in the past 5 years?

	Myself	Family Member	Close Friend
Yes	Yes Myself	Yes Family Member	Yes Close Friend

If no, please comment why this council is important to you.

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17. What hospital facility have you or your family members(s) used? Please include the year/years used.

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18. What Ambulatory/Urgent Care Centers have you or your family member(s) used?

	Myself	Family Member
North Shore-LIJ Medical Group at Flushing	North Shore-LIJ Medical Group at Flushing Myself	North Shore-LIJ Medical Group at Flushing Family Member
North Shore-LIJ Medial Group at Garden City	North Shore-LIJ Medial Group at Garden City Myself	North Shore-LIJ Medial Group at Garden City Family Member
North Shore-LIJ Medical Group at Whitestone	North Shore-LIJ Medical Group at Whitestone Myself	North Shore-LIJ Medical Group at Whitestone Family Member
North Shore-LIJ Medical Group Urgent Care Centers	North Shore-LIJ Medical Group Urgent Care Centers Myself	North Shore-LIJ Medical Group Urgent Care Centers Family Member
North Shore-LIJ Ambulatory Surgery Center	North Shore-LIJ Ambulatory Surgery Center Myself	North Shore-LIJ Ambulatory Surgery Center Family Member
Specialty Medical Center at Forest Hills	Specialty Medical Center at Forest Hills Myself	Specialty Medical Center at Forest Hills Family Member
The Alvin and Dorothy Schwartz Ambulatory Surgery Center	The Alvin and Dorothy Schwartz Ambulatory Surgery Center Myself	The Alvin and Dorothy Schwartz Ambulatory Surgery Center Family Member
None	None Myself	None Family Member

Other

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19. What Skilled Nursing Facility have you or your family members(s) used?

	Myself	Family Member
Long Island/South Oaks	Long Island/South Oaks Myself	Long Island/South Oaks Family Member
North Shore-LIJ Orzac Center for Rehabilitation	North Shore-LIJ Orzac Center for Rehabilitation Myself	North Shore-LIJ Orzac Center for Rehabilitation Family Member
The Stern Family Center for Extended Care and Rehabilitation	The Stern Family Center for Extended Care and Rehabilitation Myself	The Stern Family Center for Extended Care and Rehabilitation Family Member
None	None Myself	None Family Member

Other

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20. Please provide reference. (Not required)

Name

Relationship

Phone Number

Address

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21. I understand that completion of this application does not bind the applicant or the program coordinators in any way. North Shore-LIJ Health System reserves the right to choose participants that best meet the needs of the PFAC. Before participating, you will be asked to sign a confidentiality agreement. Please acknowledge that you have provided accurate information to the best of your ability.

Name (Signature)

Date