Patient- and Family-Centered Care Advisory Council Application

Today's Date

Name

Address

City

State

Zip

Phone

Email

What is your experience with Penn State Health? Select all that apply.

I am a patientI am a family member/support person of a patientI am an employeeI am a volunteerOther experience

Employee title

Employee work location

If Other experience is selected, please provide experience here.

With which Penn State Health location do you most frequently interact?

Penn State Health Milton S. Hershey Medical CenterPenn State Health Children's HospitalPenn State Health Medical Group – Outpatient servicesOther location

Outpatient location name

If Other location is selected, please provide location name.

When was your most recent patient experience with Penn State Health?

Less than 6 months ago6 months to 1 year ago1-3 years agoMore than 3 years ago

Please rate your experience with Penn State Health.

Very goodGoodFairPoor

What interest you most about the possibility of serving on the Patient- and Family-Centered Care Advisory Council? Select all that apply.

Making impactful change

Being part of a team

Providing opinionsOther interest

If Other interest is select, please list your interest here.

How did you hear about the Patient- and Family-Centered Care Advisory Council?

Penn State Health brochurePenn State Health employeePenn State Health websiteOther method

If Other method is selected, please list the method here.

Approximately how many meetings can you commit to in one calendar year? Meetings are held bi-monthly (Jan., Mar., May, July, Sept. and Nov.) in the evening.

1-23-45-6

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