Toronto Stroke Networks Patient and Family Advisor - Application Form Question Title * 1. Contact Information Full Name Address City/Town Province Postal Code Email Address Preferred Phone Number Question Title * 2. Which is the best way to contact you? Call my preferred phone number Send me an email Question Title * 3. What is the best time for us to contact you? Morning Afternoon Evening The following questions will help us get to know you better.... Question Title * 4. I am a.... patient/ person with stroke family member of a patient/ person with stroke Question Title * 5. When did you or your family member have a stroke? Less than 1 year ago 1-3 years ago 4-5 years ago 6-10 years ago more than 10 years ago Question Title * 6. How much time are you able to commit to being a patient and family advisor? Less than 1 hour per month 1-3 hours per month 4-5 hours per month Other (please specify) Question Title * 7. How long are you able to serve as an advisor? less than 1 year 1-2 years More than 2 years Question Title * 8. How do you want to help as an Advisor? (click all that apply) Serving as a member of the Patient and Family Advisory Committee (PFAC) Participating on short term working groups Helping develop or review educational resources Providing feedback on and helping to improve programs and clinical practices Attending focus groups Sharing your stroke experience with health care providers or others Speaking at health care or community events Providing peer support to others who have had a stroke(note: You will be referred to the March of Dimes After Stroke Program Volunteer Coordinator) Question Title * 9. Most PFAC meetings take place on weekdays during business hours (between 9am to 4pm). Are you available to join meetings during these times? Yes No Personal information contained on this form is collected pursuant to the Public Hospitals Act and the Freedom of Information and Protection of Privacy Act and will be used for the purpose of the Patient and Family Experience Advisory selection and placement for the Toronto Stroke Networks. We will not share this information otherwise without permission from the applicant/guardian. https://www.tostroke.com Done