St. Tammany Health System - St. Tammany Health System

Patient and Family Advisor Application

First Name:*

Last Name:*

Home Phone:

Office Phone:

Mobile:

Preferred Contact:*

Home

Office

Mobile

Please take a few minutes to complete the following questions that will help us to know you better.

2. Do you have preferences about the pronoun(s) others use to describe you?:

Yes

If yes, what are your preferred pronoun(s)?:

3. Have you used services at St. Tammany Health System within the past year?:*

Yes

4. Have you ever been a caregiver for a patient who has used services at St. Tammany Health System within the past year?:*

Yes

5. Please briefly describe the selected services you utilize or have utilized within the past year:

6. Please briefly describe your experience(s) with St. Tammany Health System:

7. Do you work or volunteer in your community?:

Yes

If YES, for which organizations?:

8. Are you able to meet attendance requirements, which will be 4 of 6 bimonthly (every other month) meetings?:*

Yes

9. Are you willing to sign a Confidentiality Agreement – promising to protect confidential information shared with you as a member of PFACQS?:*

Yes

10. Why are you interested in Council Membership?:*

11. What does being a Patient and Family Advocate mean to you?:*

By submitting this application, I request consideration of this application to be a member of the Patient and Family Advisory Council for Quality and Safety of St. Tammany Health System. I understand that I may have access to confidential patient information and confidential quality and safety information. I understand that I may be asked to keep all such information confidential and, if asked, that I will not share this information in any way with anyone. I understand that I will be provided specific training on policies, procedures, and confidentiality.

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