Johns Hopkins Medicine (JHM)
Patient and Family Advisory Council (PFAC) Volunteer Application
Placement Preferences: Please mark your area of interest. If you do not see the PFAC
you are applying for, please be sure you have selected the correct JHM Organization above.
Green Spring Station Ambulatory PFAC
Placement Preferences: Please mark your area of interest. If you do not see the PFAC
you are applying for, please be sure you have selected the correct JHM Organization above.
Adult PFAC
Ambulatory PFAC
Emergency Department PFAC
Oncology PFAC
Fetal Therapy Center
Pediatric Council
Center for Transgender Health PFAC
Harriet Lane Clinic PFAC
Placement Preferences: Please mark your area of interest. If you do not see the PFAC
you are applying for, please be sure you have selected the correct JHM Organization above.
Bayview General PFAC
I am/was (check all that apply)
A patient
A family member of a patient
A caregiver
My care is/was provided by (check all that apply)
Hospitalization (inpatient)
Clinic visit (outpatient)
Both inpatient and outpatient
Emergency Department Care
Other programs, departments, or services
Where did you receive your care? (check all that apply)
The Johns Hopkins Hospital
Johns Hopkins All Children's Hospital
Johns Hopkins Bayview Medical Center
Johns Hopkins Community Physicians
Johns Hopkins Care at Home
Johns Hopkins Howard Couny Medical Center
Sibley Memorial Hospital
Suburban Hospital
Johns Hopkins Surgery Centers
Non-Hospital Based Outpatient Clinic
The dates of my active experience at JHM include (check all that apply)
Within the past 2 years
More than 2 years ago
More than 5 years ago
Within the past two years, what care services have you or your family members used? (Check any that apply). We are looking for our Council members to have a range of experience with Johns Hopkins Medicine, and appreciate your sharing any information. Please be assured that this information is private and will be maintained as CONFIDENTIAL
Auto-immune
Blood and Lymphatic Defects
Cancer
Cardiology
Chest/Pulmonary
Dermatology
Ears, Nose and Throat
Endocrinology/Diabetes
Eye
Gastroenterology/GI
Intensive Care Unit
Infectious Disease
Mental Health
Nephrology/Kidney
Neurology/Neurosurgery
Nutrition
Orthopedic
Plastic Surgery
Pregnancy, Childbirth, Infant Care
Rehabilitation
Skin and Connective Tissues
Surgery
Transplant
Urology
Other
Times when you are able to engage in PFAC work (check all that apply)
Daytime
Evening
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
* Why would you like to serve as an advisor?
I would be interested in helping with (identify all of your interest areas)
Developing/reviewing educational materials to improve the patient and family experience.
Planning for the hospitalization (inpatient) care experience for adults.
Planning for the hospitalization (inpatient) care experience for children.
Planning for the emergency care experience.
Planning for the clinic (outpatient and ambulatory) care experience.
Planning for the oncology care experience.
Planning the design of systems of care and facilities for the emergency experience.
Educating medical students and residents, new nurses and other employees, and other staff about the experience of care and effective communication support.
Participating in facility design planning.
Improving the coordination of care and the transition to home and community care.
Issues of special interest.
I would be interested in helping with (identify all of your Ambulatory interest areas)
Developing/reviewing educational materials to improve the patient and family experience.
Planning for the clinic (outpatient and ambulatory) care experience.
Planning for the oncology care experience.
Planning the design of systems of care and facilities for the emergency experience.
Educating medical students and residents, new nurses and other employees, and other staff about the experience of care and effective communication support.
Participating in facility design planning.
Improving the coordination of care and the transition to home and community care.
Issues of special interest.
* If you have served as an advisor, been an active volunteer committee member, or done public speaking for other programs or organizations, please briefly describe this experience:
* Tell us about your or your family's healthcare experience at the location where you are applying. What would you have improved about this experience? What impressed you about this experience?
* 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?
Is there anything that you would like us to know?
Confidentiality Agreement
If you know other individuals who have experienced care at Johns Hopkins Medicine and may be interested in serving
on the council, please share our information.
CONFIDENTIALITY: All information contained in this form is considered confidential and is intended for use by a
Johns Hopkins Medicine Patient and Family Advisory Council Membership Committee. The Committee will maintain
appropriate and confidential handling of personal information as stated in HIPAA guidelines and is presented in
volunteer training. Qualified applicants will be selected to participate in a face-to-face interview. If selected,
all Patient and Family Advisory council applicants must complete volunteer service requirements as assigned by the
Volunteer Services department. These volunteer requirements include, but are not limited to the completion of the
following: volunteer application, reference and criminal background check, volunteer orientation, HIPAA training
and badge identification.
All patients and families served by Johns Hopkins Medicine are welcome to apply for membership as a Patient
and Family Advisor.
Applicant Signature: (Draw your signature into the box below)
