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Patient and Family Advisor Council Application
Patient and Family Advisor Council Application
Contact Us
440.312.4500
Contact Us
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Patient and Family Advisor Information
First name
Last name
Street address
City
State
Zip Code
Home Phone
Cell Phone
Work Phone
000-000-0000
Fax
If yes please complete the 5-page college student volunteer application instead of the contact form.
Email
Language(s) You Speak
Will you allow your contact information to be shared with other committee/Advisory council members?
Yes
No
I am
A Patient
A Family Member of a Patient
Patient Care Information
Cleveland Clinic location where care was provided
Type of care provided at Cleveland Clinic
Hospitalization (inpatient)
Emergency Department care
Clinic visit (outpatient)
Other programs, departments, or services
Both inpatient and outpatient
Dates care provided at Cleveland Clinic
2013 to present
2012-2010
Earlier than 2009
Within the last two years, what care services have you or your family member used?
AIDS and HIV
Cancer
Cardiology
Chest/Pulmonary
Ear, Nose, Throat
Endocrinology/diabetes
Eye
Gastroenterology/GI
Genetics/Birth Defects
Intensive Care (ICU)
Infectious Diseases
Neurology
Orthopaedic
Pregnancy/Childbirth, Infant Care
Rehabilitation
Surgery
Transplant
Urology
Other (Please list alphabetical)
Advisor Information
Interest areas:
Cancer Patient Support
Caring Canines (Must have/own dog)
Clerical
Cleveland Clinic Children's
Emergency Department
High Tea
Information Desk
Inpatient: Visiting patients and providing non-clinical support
Lounges: ICU and Surgical
Outpatient: Lobby rounds, clerical support, stock supplies
Patient Mail
Radiology Transport
Spiritual Care Department
Why would you like to serve as an advisor?
Please list when you are available to attend meetings
Daytime
Evening
Weekend
I would be interested in helping with
Reviewing patient and family satisfaction tools.
Developing/reviewing educational ,materials.
Planning for the hospitalization (inpatient) care experience.
Planning for the design of systems of care and facilities for the surgical experience.
Planning for the clinic (outpatient or ambulatory) care experience.
Planning the design of systems of care and facilities for the emergency care experience.
Ensuring patient safety and the prevention of medical errors.
Educating medical students, residents, new employees, and other staff about t the experience of care and effective communication and support.
Participating in facility design planning.
Improving the coordination of care and the transition to home and community care.
Long-term advisory council membership to have impact and influence on policies and practices that affect the care and services patients receive.
Issues of special interests
If you have served as an advisor, been an active volunteer committee member, or done public speaking for other programs or organizations, please briefly describe this experience.
What are some specific things that health care professionals did or said that was most helpful to you and your family?
What are some specific things that you or your family would like health care professionals to do differently in order to be more helpful?
Do you know other individuals and/or families who have experienced care at Hillcrest Hospital who might be interested in serving as advisors? Please call them for us or list their name(s) and phone number(s) here:
Questions?
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