Patient and Family Advisory Council for Quality and Safety (PFACQS) Questionnaire

Applicant Information

Name*

Please tell us about your experience at MedStar St. Mary’s Hospital.

Have you ever been hospitalized at MedStar St. Mary’s Hospital for more than 24 hours?*
Have you ever been a caregiver for a patient who was hospitalized at MedStar St. Mary’s Hospital for more than 24 hours?*

Please tell us more about you.

Are you employed by MedStar St. Mary’s Hospital?*
Is English your first language?*

Eligibility Criteria:

Are you able to attend meetings at MedStar St. Mary’s Hospital during weekday evenings?*
Are you willing to take the necessary immunizations to serve on the Patient Family Advisory Council for Quality and Safety?*
Are you willing to sign an agreement promising not to disclose confidential information given to you in your role as a member of the Patient Family Advisory Council for Quality and Safety?*
Are you willing to undergo a background check?*

This form is secured and the information that you provide is confidential.

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