APPLICAT
TION TO JOIN
N PATIENT AN
ND FAMILY AD
DVISORY COU
UNCIL Please priint: Name: __
____________
___________
____________
_____________________________________ (Last) (Firsst) (MI) Address: _
___________
___________
____________
_____________________________________ City: ____
___________
______ State: ___________
_________ Ziip Code: _____________________ Home Pho
one: (10 digitts) _________
___________
_ Cellular Pho
one: (10 digitss) ____________________
one: (10 digitss) _________
___________ Fax: (10 digitts) _____________________ Work Pho
E‐mail Ad
ddress: _____
____________
___________
___________________________________ Language
e(s) You Speak: _________
____________
____________________________________ Will you a
allow your co
ontact inform
mation to be sshared with o
other committtee/advisoryy members?
Yes No I am: (fill‐‐in all that app
ply) A patie
ent A family member off a patient Other, please speciffy: _________
___________
____________
________________________ Please listt times when
n you are able
e to attend m
meetings: (fill‐‐in all that ap
pply) Daytim
me: ________
__ Evenin
ng: _________
_ Weeke
end: _______
___ My care p
provided by M
Memorial was primarily:
(Fill‐in all that applies aand supply month and yeaar of care) Hospitalization (inpatient): MM//YY Clinic vvisit (outpatie
ent): MM/YY Emergency Departm
ment care: MM/YY Other programs, de
epartments, o
or services: M
MM/YY Both in
npatient and outpatient: M
MM/YY I/We wou
uld be interessted in helpin
ng to improve
e: (Fill‐in all thhat apply) Patientt and family ssatisfaction to
ools Patientt educationall materials The ho
ospitalization (inpatient) caare experiencce (room, cooordination of care, commu
unication, food) The care systems an
nd facilities fo
or the surgicaal experience
The clinic (outpatient or ambulattory) care exp
perience The care systems an
nd facilities fo
or the emerge
ency care expperience Patientt safety and tthe preventio
on of medical errors Educattion of medical students and residents, new employyees, and otheer staff aboutt the experien
nce of care an
nd effective co
ommunicatio
on and supporrt Facilityy design plann
ning and wayy‐finding The co
oordination off care and the
e transition to
o home and ccommunity caare Issues of special interest (please describe): Tell us mo
ore about yourself. Please shaare with us yo
our passion fo
or being a pattient/family ppartner. Family‐Ce
entered Care programs strive to reflect the cultural ddiversity of faamilies and co
ommunities. To the degre
ee that you feel comfortable, please shaare anything aabout your faamily that you
u think would
d add to the divversity of this program. Please shaare your expe
erience or exp
posure to working in grou ps/councils, iincluding how
w you handled
d sensitive ttopics and infformation. What wou
uld you like to
o share aboutt your experie
ence receivinng care througgh Memorial and its Family of Services? Reference
e: Please incclude the nam
me of a person
nal or professsional referennce or a Mem
morial staff meember who kknows you and/o
or your familyy member (do
octor, therapist, social wo rker, etc.) ____________
___________
____________
__________________ Name: __
nformation: _
____________
___________
____________
____________________ Contact In
_
___________
____________
_______________________________ _
___________
____________
_______________________________ Please re
eturn completed applicaation to: Claudia Faucher
Yakima Valley Memorial Hospital
2811 Tieton Drivel, Yakima WA 98902
Phone 575-8768
Fsx 574-5800
Email: [email protected]