St. Francis Medical Center - Patient & Family Advisory Council for Quality & Safety Application

St. Francis Medical Center - Patient & Family Advisory Council for Quality & Safety Application
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Name*

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I am a

PatientFamily member
The following questions will help us to get to know you better:
If you feel comfortable sharing, what was the reason you came to the hospital or what was the reason your family member came to the hospital?
Tell us about your experience. What impressed you about your experience? What would you improve?
Why do you want to volunteer to be a part of the Patient and Family Advisory Council?
Are you available to serve as an advisor for at least 3 years?

YesNo
If you have participated in any organizations or committees, please share some examples: (These may be from work, community, church)
Our Patient and Family Advisors reflect the diversity of the patients and families we serve. Please share anything about yourself that you think would add to the diversity of our team of advisors.
Is there anything else you would like us to know?
Before participating in the PFACQS you will be asked to sign a confidentiality agreement and be screened and oriented through St. Francis Medical Center Volunteer Services. You will also be asked to attend a Patient and Family Advisory Council for Qualtiy and Safety Orientation.

Thank you for your interest. Please feel free to contact Ajazhane Horne at ajazhane.horne@fmolhs.org or 318-966-4352 with any questions or for more information.
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