Patient and Family Advisor Application Form

Thank you for your interest in becoming a Patient and Family Advisor (PFA) at Health Sciences North (HSN). Although PFAs do not have direct contact with patients, their role is vital to HSN as their opinions, ideas and input help influence change and have an impact on the care and services we provide to our patients and families.

Selection of PFAs will be based upon the following criteria:

Have had both positive and negative perceptions of their hospital experience.
Reflect the diversity of those served by the hospital
Is not employed directly by HSN

*Only selected applicants will be contacted for an interview.

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* Last Name

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* First Name

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* Email address

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* Primary phone number?

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* Preferred method of communication?

Phone

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* Mailing Address

Address

City/Town

Province

Postal Code

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* In the past 2 years, have you or a family member accessed services of Health Sciences North?

Yes

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* How did you hear about the Patient and Family Advisory Program?

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* Do you consider yourself to be....

White

Black or African American

Hispanic or Latino

Asian or Asian American

Indigenous/Aboriginal ( First Nation, Inuit, Metis etc..)

South Asian (East Indian, Pakistani, etc..)

Another race

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* How do you describe your gender identity? (check all that apply)

Genderfluid or genderqueer

Man

Nonbinary

Transgender man

Transgender woman

Two-Spirit

Woman

Questioning or unsure

Prefer not to answer

Other (please specify)

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* Current status that best describes you (please check one)

Employed

Seeking employment

Student

Retired

Other (please specify)

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* Why would you like to serve as a patient or family advisor?

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* What are some areas of special interest to you?

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* I would be interested in helping with:

Reviewing patient and family satisfaction surveys

Improvement projects for Strategic Plan, Quality Improvement Plan

Developing/Reviewing patient/family education materials

Developing/Reviewing staff education materials

Co-facilitating new staff education sessions (patient and family centered care content)

Peer leader training and co-facilitation of patient work shops

Sharing patient stories (public speaking)

Family and Child Program

Cancer Care

Renal Program Accessibility

Mental Health and Addictions Medical Program

Pharmacy Services

Rehabilitation

Respiratory Therapy

Surgical Program

Emergency Services

Cardiology

Intensive Care Unit

Palliative Care

Hiring Interviews

Research Activities

Other (please specify)

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* Do you have any skills that would be advantageous to HSN

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* Please read and check before sending the application:

I understand that, upon acceptance into an advisory position, HSN requires that I submit the results of a criminal reference check. More details are provided at the acceptance stage.

I understand that prior to beginning as an advisor; I can choose to submit the results of a negative 2-step Tuberculosis (TB) test and provide proof of immunization. More details are provided at the acceptance stage.

I understand that prior to beginning as an advisor I must sign a confidentiality agreement.

I understand that as as advisor I will be accountable to the HSN Patient and Family Advisor Coordinator.

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* Please provide the name of a person not related to you who will provide a character reference for you

1. Reference

Name

Email Address

Phone Number

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* 2. Reference

Name

Email Address

Phone Number

Applicants who are selected for an interview will normally be contacted within 30 days of submission of the application form.
All information contained on this form is considered confidential and is intended for use by Health Sciences North's Patient and Family Advisor Liaison only. You may be contacted upon receipt of this application form to participate in a face-to-face interview.

If you have any questions please email them to: pfaprogram@hsnsudbury.ca

Thank you for your interest in becoming a Patient and Family Advisor.

Patient and Family Advisor Application Form

Question Title

* Last Name

Question Title

* First Name

Question Title

* Email address

Question Title

* Primary phone number?

Question Title

* Preferred method of communication?

Question Title

* Mailing Address

Question Title

* In the past 2 years, have you or a family member accessed services of Health Sciences North?

Question Title

* How did you hear about the Patient and Family Advisory Program?

Question Title

* Do you consider yourself to be....

Question Title

* How do you describe your gender identity? (check all that apply)

Question Title

* Current status that best describes you (please check one)

Question Title

* Why would you like to serve as a patient or family advisor?

Question Title

* What are some areas of special interest to you?

Question Title

* I would be interested in helping with:

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* Do you have any skills that would be advantageous to HSN

Question Title

* Please read and check before sending the application:

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* Please provide the name of a person not related to you who will provide a character reference for you1. Reference

Question Title

* 2. Reference

* Please provide the name of a person not related to you who will provide a character reference for you

1. Reference