PFEC Council Application

Patient Family Engagement Council Application
Full Name*

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*
E-mail*
example@example.com
Tell us a bit about your connection or experience with Good Samaritan:*
Can you name 2 or 3 strengths that you think Good Samaritan has in terms of working with patients and families?*
Can you recall a situation you have encountered at Good Samaritan that could have been improved?*
In general, can you offer 2 or 3 suggestions for improving Good Samaritan's services to patients and families?*
Why would you like to participate in the Good Samaritan Patient and Family Engagement Council?*
Have you ever been or currently are an employee at Good Samaritan?*

NoYes, I was employedYes, I am a current employee
If you were selected for the PFEC, what would be your ideal meeting day and time of day?*
Do you agree or disagree with the following statement: I feel comfortable expressing myself*

AgreeDisagree
Do you agree or disagree with the following statement: I have trouble putting my ideas into words*

AgreeDisagree
Do you agree or disagree with the following statement: I usually keep to myself*

AgreeDisagree
Would you be willing to come in to Good Samaritan for an in-person interview?*

YesNo
Should be Empty:

Patient Family Engagement Council Application