MSMH Organic PFACQS Application Form

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

Applicant Information

Name*

First Name

Last Name

Email Address

Home Phone*

Address 1*

Address 2

City*

State*

Postal Code*

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?*

Yes No

How long was your longest hospitalization? *

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

Yes No

How long was the longest hospital stay of the person you were caring for? *

How many times have you or a person in your care been hospitalized at MedStar St. Mary’s Hospital in the last three years? *

How would you describe your hospital experience at MedStar St. Mary’s Hospital?*

What did the hospital do well during your stay or your loved one’s stay?*

What could the hospital have done better?*

Please tell us more about you.

Are you employed by MedStar St. Mary’s Hospital?*

Yes No

How long have you been employed at MedStar St. Mary’s Hospital?*

What is your role at MedStar St. Mary’s Hospital?*

Do you volunteer in your community? If so, for which organizations?*

Do you feel comfortable working in groups, speaking up and providing input?*

Is English your first language?*

Yes No

What is your primary language?*

Eligibility Criteria:

Are you able to attend meetings at MedStar St. Mary’s Hospital during weekday evenings?*

Yes No

Are you willing to take the necessary immunizations to serve on the Patient Family Advisory Council for Quality and Safety?*

Yes No

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?*

Yes No

Are you willing to undergo a background check?*

Yes No

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Campaign Medium

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