JHH PFAC Volunteer Application

Thank you for your interest in joining a Johns Hopkins Hospital Patient and Family Advisory Council! Council members are essential partners in the Hospital's mission to provide excellent patient- and family-centered care.

Please fill out this secure form. If you have any questions, feel free to contact us at patientfamilycouncil@jhmi.edu.

New User Details

User ID

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Password

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Patient and Family Advisory Council (PFAC) Volunteer Application: Adult, Ambulatory, Emergency Department, Oncology, Fetal Therapy Center, Pediatric, Harriet Lane Clinic, and CTH Councils

Placement Preferences: Please mark your area of interest

Adult PFAC

Ambulatory PFAC

Emergency Department PFAC

Oncology PFAC

Fetal Therapy Center

Pediatric Council

Center for Transgender Health PFAC

Harriet Lane Clinic PFAC

Contact Information

* First Name

* Last Name

Preferred Pronouns

Other Pronouns

* Home Address

* City

* State

* Zip Code

* Primary Phone

Secondary Phone

* E-mail Address

* DOB

Will you allow your contact information to be shared with other committee/advisory council members?

Primary Language

Additional Language(s): select all that apply

Education

Highest Grade Level Completed

Employer's Name/School's Name

Occupation/Academic Major

Emergency Contact

* Contact Name

* Relationship

Phone Number

Care Experience

I am/was (check all that apply)

My care is/was provided by (check all that apply)

If you selected 'Other' please specify

Where did you receive your care? (check all that apply)

The dates of my active experience at JHMI include (check all that apply)

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 The John Hopkins Hospital, and appreciate your sharing any information. Please be assured that this information is private and will be maintained as CONFIDENTIAL

If you selected 'Other' please specify

Council Information

Times when you are able to engage in PFAC work (check all that apply)

How did you hear about PFAC?

If you selected 'Other' please specify

* Why would you like to serve as an advisor?

I would be interested in helping with (identify all of your interest areas)

If you selected 'Issues of Special Interest' please specify

* 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 JHH. 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?

Have you been recommended to join the PFAC from a Johns Hopkins healthcare professional?

May we contact them?

Name and phone number of recommender

Confidentiality Agreement

Click here to review the Confidentiality Statement

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

Final Steps

Are you at least 18 years of age?

Parent/Guardian's Name(if under 18yrs old)

If you know other individuals who have experienced care at Johns Hopkins Hospital 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 the Johns Hopkins Hospital Patient and Family Advisory Council Membership Committee. The Committee will maintain appropriate and confidential handling of personal information as stated in HIPPA 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 the Johns Hopkins Hospital are welcome to apply for membership as a Patient and Family Advisor.

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Date

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