Patient Family Advisory Council Application

Emergency Contact
Emergency Contact Name*
Who would you like us to contact in the event of an emergency?
Relationship*
Phone Number*
Please enter a valid phone number.

Getting to Know You
Have you or one of your family members been a patient at one of the NCH hospitals within the last two years?

YesNo
What was the approximate duration of stay?*
If a family member, what is the relationship to the patient?*
What department or unit did you or your family member stay on? (Select all that apply)
Why are you interested in joining the Patient Family Advisory Council?*
Do you currently serve on any committees or board of directors?

YesNo
If yes, which ones and in what capacity?
The Patient Family Advisory Council will meet no more than ten times per year. Are you able to attend 80% (8 meetings) per year?

YesNo
What strengths and/or talents would you like to offer the Patient Family Advisory Council?
As needed, our NCH Patient Family Advisory Council members serve on miscellaneous committees. These committees are formed to expedite hospital functions such as policies, billing, discharge planning, inpatient experience, etc. Please state any committee preference(s).
Are you or an immediate family member being compensated in any way by NCH (pharmaceutical company, medical device)

YesNo
If yes, please explain the nature of the relationship and the vendor.

Background Information
Have you ever been employed by NCH or any of its affiliates?

YesNoNCH employment application in progress
Have you have ever been charged with or convicted for a crime.

YesNo
If yes, explain and provide the location (county and state).
Have you been charged with an unresolved criminal charge. (Are you charged with a crime that has not yet resulted in a plea of guilty, court trial, deferred adjudication or dropping of the charge?)

YesNo
If yes, explain and provide the location (county and state).
Are you currently on probation.

YesNo
If yes, explain and provide the location (county and state).
NCH conducts criminal record checks on all incoming members of the Patient Family Advisory Council. This is done in accordance with the law and in an effort to enhance patient safety. Falsification or failure to disclose complete information will disqualify you from service. A conviction does not necessarily disqualify you from service.

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I certify that the information given above is complete and accurate and I understand that misrepresentations and/or withholding of information will result in termination of this application or discharge (if discovered after acceptance).

I understand that I will not be paid for my services as a member of NCH Patient and Family Advisory Council.

I agree to abide by the guidelines of the NCH Patient and Family Advisory Council, to respect confidentiality, and to uphold the standards of NCH. I understand that membership to the NCH Patient and Family Advisory Council will be based on a preliminary interview, panel interview and final approval by the Council.
Advisory Council Agreement*

I agree
Date*

MonthDayYear
Date
Enter your full name as your electronic signature here.*
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