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Patient Family Advisory Council

Patient and Family Advisory Council Application

Understanding the care experience from the perspectives of our patients and their families is a key factor in delivering healthcare quality, safety and service. In our ongoing efforts to provide exceptional patient care, we are enlisting the assistance of former patients and their families to share their perspectives, insights and experiences.

We are currently in the process of selecting patients and family members to help us create a sustainable Patient and Family Advisory Council (PFAC). As a member of the Council, you will assist with the development of the structure for the PFAC (membership, frequency of meetings, length of meetings, goals, etc.). The estimated time commitment for the PFAC is 8 meetings at 2 hours per meeting, and beyond that will be determined by the committee.

If you would be interested in serving on the PFAC, please complete this short application, or you can pick up a hardcopy at Memorial Hermann Katy Hospital, 23900 Katy Freeway, Katy Texas 77494. Selected applicants will be contacted to schedule an interview. If you have any questions, please call Ashley Dubbelde at (281) 644-8033.

  

 First name:
 

Last name:
 

Address:
 

City:
 

State:
TEXAS

Zip:
 

Daytime phone:
 

Email address:
 

Age:

 

I am:

 

Are there certain topics or areas of the hospital in which you have a special interest?

In what area(s) are you interested in representing? Please check all that apply.

        


Why are you interested in Joining the Patient and Family Advisory Council?


If you have participated in any organizations or committees, please share some examples: (These may be from work, community, church)


What positive improvements to patient care would you like to see as a result of your participation in the Patient and Family Advisory 
Council?


Do you have any dietary needs we should be aware of? (i.e., vegetarian)


Electronic Signature:
 


REMINDER: WE WILL DO BACKGROUND CHECKS ON ALL COMMITTEE MEMBERS, AND A HEALTH SCREENING (FLU AND TB) IS REQUIRED BEFORE YOU JOIN AND ANNUALLY GOING FORWARD. MEMBERS MUST SIGN A CONFIDENTIALITY AGREEMENT. WE WILL KEEP APPLICANTS IN MIND FOR POTENTIAL OPPORTUNITIES FOR FUTURE PROJECTS.