PFAC New Member Application

CHA Patient & Family Advisory Council (PFAC) New Member Application

To apply to join CHA's PFAC as a member please complete the application below.
Please use this secure form to apply for CHA Patient and Family Advisory Council. Please note, all information provided is confidential.
Name*

First NameLast Name
Pronouns*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Preferred Phone*
Please enter a valid phone number.Format: (000) 000-0000.
Is this a home or cell phone?*

HomeCell
Email*
example@example.com
I am a*

PatientFamily MemberBoth Family Member & Patient
Do you have MassHealth?

YesNo
Have you or a family member received care at CHA within the last two years?*

YesNo
Are you currently a CHA employee?*

YesNo
Are you able to commit 1-4 hours per month for one year?*

YesNo
Are you comfortable speaking openly in a large group?*

YesNo
Are you interested in working as part of a team on projects, committees and focus groups? Please check all options you are interested in.*

eAdvisorProject AdvisorStorytellerCommittee AdvisorPFAC AdvisorFocus Group AdvisorPt Experience VolunteerOther
If yes, please select what you would be interested in working with

eAdvisorPerformance Improvement Project AdvisorPFAC Advisor (Pt & Family Advisory Committee)PX VolunteerFocus Group AdvisorStorytelling AdvisorOther
Are you excited to make meaningful, positive improvements for all patients and their families?*

YesNo
Languages you speak*
Our Patient Advisor Program reflects the diversity of the patients and families we serve. Please share anything about yourself that you think would add to the diversity of our team of advisors. Please consider diversity to be any of the following or more: ethnic, racial, spiritual, social, economic, educational, geographical, gender, sexual orientation, unique family structure, disability, chronic illness, single parent, full-time parent, grandparent, student, etc.*
Please tell us about your experience receiving care at Cambridge Health Alliance*
Please tell us why you would like to be a member of our Patient and Family Advisory Council and volunteer your time to improve the patient experience?*
How did you learn about being a Patient Advisor at CHA?*
Do you require any special accommodations in order to participate in meetings (e.g. handicap access, food allergies, language interpreter)?*

YesNoPrefer not to answer
I certify that all statements on this application are true and complete. I understand that the selection as a PFAC member is contingent upon CORI check. I agree to abide by the guidelines of the Council, to respect patient confidentiality, and to uphold CHA values of Community, Integrity, Respect, Compassion, Learning and Excellence. I understand that as a Patient & Family Advisory Council member, I am making a commitment to attend one meeting per month for my accepted term. If selected for PFAC membership, I understand that any falsification of, or omission from this application may result in termination of such membership.*

I agreeI do not agree
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CHA Patient & Family Advisory Council (PFAC) New Member Application