All Children's PFAC Application

Johns Hopkins All Children's Hospital (JHACH) Patient and Family Advisory Council (PFAC) Volunteer Application

Contact Information

* First Name

MI

* Last Name

First name (preferred)

Preferred Pronouns

Other Pronouns

* Date of Birth

* Home Address

* City

* State

* Zip Code

* Primary Phone (Mobile)

Secondary Phone (Home)

* E-mail Address

Preferred Form of Contact

Primary Language

Additional Language(s): select all that apply

Shirt Size

How did you hear about PFAC?

Online (The Johns Hopkins Medicine Website Social Media Other)

Current or Former Council Member

Johns Hopkins Employee

Friend/ Family Member/ Caregiver

Event

Other

If you selected 'Other' please specify

Education

Highest Grade Level Completed

Patient Information

* Patient First and Last Name(s)

Emergency Contact

* Contact Name

* Relationship

* Phone Number

Care Experience

What areas provide care to you and your family?

Inpatient Units (inclusive of NICU)

Outpatient Physician Clinics

Outpatient Services (Lab Radiology OT/PT/Speech Audiology etc.)

Emergency Center

Ambulatory Surgery

* Why are you interested in joining JHACH's PFAC?

* What is an area of patient care that is particularly important to you?

* If asked to talk to a group of health care professionals, please give us an example of the three most important pieces of insight you would like them to take away from your presentation:

* JHACH strives to provide exceptional care without exception. What does this mean to you?

* We believe that the Patient and Family Advisory Council (PFAC) should reflect the diversity of patients and families who receive care at JHACH. Please share anything about yourself that you think would add to the diversity of our PFAC. Please consider diversity to include any of the following or more: race, ethnicity, gender, sexual orientation, disability, spiritual, economical, educational, etc.

Council Information

The PFAC generally meets on the third Tuesday of the month (September through June) from 6:00pm - 7:30pm. Can you meet during those specified times?

How much time are you able to commit to being a patient and family advisor?

Are you able to make the commitment to be an advisor for at least 3-4 years?

Are you comfortable with participating in both in-person and virtual meetings [*Virtual meetings are held on the Zoom platform]

* To best serve you in our future communication, do you have any special needs/limitations (e.g., hearing impairment, vision impairment, mobility challenges, etc.) you would like us to aware of when scheduling meetings?

Is there anything that you would like us to know?

Confidentiality Agreement

Click here to download the Confidentiality Statement

* By checking this box, I agree that I have downloaded, read, and understand the JHM Confidentiality Statement.

* Confidentiality Agreement Date:

Final Steps

Confidentiality: All information contained in this form is considered confidential and is intended for use by the Johns Hopkins All Children's Patient and Family Advisory Council Committee. The Committee will maintain appropriate and confidential handling of personal information as stated in HIPAA guidelines. Qualified applicants will be selected to participate in an interview. If selected, all Patient and Family Advisory Council applicants must complete Volunteer Services requirements as assigned by the Volunteer Services Department within 60 days of acceptance into the council. These volunteer requirements include, but are not limited to, TB test, immunizations, background check, HIPAA/compliance overview and Volunteer Services orientation/onboarding. I certify that the answers given by me are true, accurate and complete. I understand that by submitting an application, I am 18 years of age, I am applying for a patient and family advisor appointment, and that this is not an application for, or contract of, employment. If appointed, I will submit to all hospital requirements and take all required trainings where applicable. I understand that as an advisor, I will not be compensated for my time.

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Applicant Signature: (Draw your signature into the box below)

Date

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