Expression of Interest - Ontario Health North: North East and North West Patient & Family Advisory Councils (PFAC)

Hello, Aanii, Bonjour! Thank you for your interest in becoming an Ontario Health North Patient and Family Advisory Council (PFAC) member. We are establishing two PFAC’s – one for Northeastern Ontario and one for Northwestern Ontario.

Please take a few minutes to complete the survey below and tell us a bit more about yourself, your interests and experiences.

Please note: We are available to support you through this process. If you have any questions or need any accommodations to complete the form below, please contact, Katerine Moyer at Katerine.moyer@ontariohealth.ca or 705-358-2508.

All applications will be reviewed, and we will invite potential candidates for an informal telephone or video interview. Membership will be selected to ensure diversity that is reflective of the area’s population, in relation to age, geographic distribution, cultural diversity, socio-economic status and experience with the health system.

Question Title

* 1. Contact Information

Your Name (First and Last):

Address:

City/Town

Phone Number:

Email:

Question Title

* 2. Which of the following best describes the type of community that you live in?

population less than 3,000 people

3,000 – 10,000 people

10,000 – 40,000 people

40,000 – 60,000 people

60,000 – 100,000 people

Other (please specify)

Question Title

* 3. Which part(s) of the health care system do you have experience with? (Please check all that apply)

Hospital

Home and Community Care

Community Health Centre

Community Mental Health

Addictions Agency or Program

Community Support Services Organization (i.e. Alzheimer's Society, Meals-on-Wheels, etc.)

Indigenous Health

Long-Term Care

Primary Care (Family Physician/Nurse Practitioner/Family Health Team)

Hospice Palliative Care

Other (please specify)

Question Title

* 4. Without sharing any personal health information, briefly describe your experience with the health care system and what unique perspective and strengths you would bring to the council?

Question Title

* 5. What are the top 1-3 things you think would help to strengthen the health system across Northern Ontario?

Question Title

* 6. Are you able to commit to meeting a minimum of 4 times per year?

Yes

Comment

Question Title

* 7. Are you currently involved with an Ontario Health Team (OHT)?

Yes

If yes, which one:

Question Title

* 8. What other committees, patient advisory committee, volunteer work or boards are you currently involved in and/or have you been involved with in the past two years?

Question Title

* 9. What excites you about becoming a member of the North East Region PFAC?

Question Title

* 10. Any additional comments you would like to add?

The following questions are optional, but responses help us better address the diversity needed for the Council. This information is confidential.

Question Title

* 11. I identify my gender as:

Question Title

* 12. Please indicate your age range:

18-25

26-39

40-55

56-64

65-75

76+

Question Title

* 13. Please tell us if you self-identify with any of the following:

Indigenous

Francophone

Newcomer (An immigrant or refugee who has been in Canada for a short time, usually less than 3 or 5 years)

LGBTQIA2S+

Racialized, ethnic and/or cultural minority group

Individual or family from lower income household

A person with a disability or accessibility challenge

Other (please specify)

*We thank you for your interest and taking the time to complete this application. All applicants will be contacted as to the status of their application. All information contained on this form is considered confidential and is intended for use only for the recruitment of the Ontario Health North Patient and Family Advisory Councils.