Done Patient and Family Advisory Council Application About You Question Title 1. Contact Information Name: Company if applicable: Address: City/Town: State: -- select state -- AL AlabamaAK AlaskaAS American SamoaAZ ArizonaAR ArkansasCA CaliforniaCO ColoradoCT ConnecticutDE DelawareDC District of ColumbiaFM Federated States of MicronesiaFL FloridaGA GeorgiaGU GuamHI HawaiiID IdahoIL IllinoisIN IndianaIA IowaKS KansasKY KentuckyLA LouisianaME MaineMH Marshall IslandsMD MarylandMA MassachusettsMI MichiganMN MinnesotaMS MississippiMO MissouriMT MontanaNE NebraskaNV NevadaNH New HampshireNJ New JerseyNM New MexicoNY New YorkNC North CarolinaND North DakotaMP Northern Mariana IslandsOH OhioOK OklahomaOR OregonPW PalauPA PennsylvaniaPR Puerto RicoRI Rhode IslandSC South CarolinaSD South DakotaTN TennesseeTX TexasUT UtahVT VermontVI Virgin IslandsVA VirginiaWA WashingtonWV West VirginiaWI WisconsinWY Wyoming ZIP: Phone Number: Alternate Phone (cell) Email Address: Question Title 2. Are you presently employed? Yes No Question Title 3. If so, what is your occupation? Question Title 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) Question Title 5. Race (optional) Asian Black/African American Caucasian Hispanic/Latino Other, specify (optional) Question Title 6. Age (optional) 18-30 31-40 41-60 61-80 Over 81 Question Title 7. Primary language that you speak. Question Title 8. List any other languages that you speak. Question Title 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: Question Title 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. Question Title 11. Why are you interested in becoming a member of the Patient and Family Advisory Council? Please be as specific as possible. Question Title 12. What area(s) of interest would you like to see the Patient and Family Advisory Council address? Question Title 13. What can you contribute to the Patient Family Advisory Council? Question Title 14. Do you now, or have you ever worked for North Shore-LIJ Health System as an employee, volunteer or medical staff member? Yes No If yes, please list the position, department and dates Question Title 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) Question Title 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. Question Title 17. What hospital facility have you or your family members(s) used? Please include the year/years used. Question Title 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 Question Title 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 Question Title 20. Please provide reference. (Not required) Name Relationship Phone Number Address Email Question Title 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 Done