About You

1. Contact Information

2. Are you presently employed?

3. If so, what is your occupation?

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

5. Race (optional)

6. Age (optional)

7. Primary language that you speak.

8. List any other languages that you speak.

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?

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.

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

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

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

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

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.

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

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

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 Medial Group at Garden City
North Shore-LIJ Medical Group at Whitestone
North Shore-LIJ Medical Group Urgent Care Centers
North Shore-LIJ Ambulatory Surgery Center
Specialty Medical Center at Forest Hills
The Alvin and Dorothy Schwartz Ambulatory Surgery Center

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

  Myself Family Member
Long Island/South Oaks
North Shore-LIJ Orzac Center for Rehabilitation
The Stern Family Center for Extended Care and Rehabilitation

20. Please provide reference. (Not required)

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.