Person and Family Advisory Council Information Sheet (Step 1 of 2)

At Ascension we believe in a patient-centered approach to care delivery. As a PFAC member, you'll participate in critical conversations to help shape the future of healthcare, help us better understand areas needing improvement by sharing real-world experiences, provide feedback on early ideas/concepts and co-create with our design teams as we reimagine care. We’re thrilled that you’re interested in bringing your experiences, suggestions & observations to the table.

Name*

Address*

City/Town*

State/Province*

ZIP/Postal Code*

Email Address*

Phone Number*

Which facility do you receive care?*

Are you interested in serving on a national panel?*

(The national panel of advisers will only convene through short online surveys, email, phone calls, and web meetings)

Select or enter value

Are you interested in serving on the local PFAC?*

(The local panel will convene based on the location)

Select

May we contact you by phone, text or email?*

(Select all that apply)

Select or enter value

What is your age?*

Select

Are you United States Military?*

Select

What is your primary language?*

Select

What is your highest level of education?*

Select

What age are the children you care for (check all)*

Select

Are you Hispanic or Latino orgin?*

Select

What is your race? (Check all that apply)*

Select

Recent Healthcare experiences:*

(Please select any experiences you or your family has had in the last year)

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If other, please explain:

Please indicate who these services were for:

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Would you provide feedback on this care?*

Select

Special interests and topics:*

Innovations in care Patient Safety Disparities in care Community wellness Patient family experience Other (select all that apply)

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If other please explain:

Tell us about your interests, skills and talents.*

(in a few sentences)

In a few sentences tell us your healthcare story:*

(Your experiences and perspective can help improve healthcare in your community.)

Thank you!

Thank you for your interest in our PFAC. You will be directed to complete our Confidentiality Agreement after submitting this form.

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