Patient & Family Advisory Council Application

Thank you for your interest in our Patient and Family Advisory Councils.

Requirements necessary in order to be considered for the PFAC

Embrace our Values

Be respectful of others and their opinions, exhibit good listening skills
Show compassionate and be non-judgmental
Be accountable for protecting the privacy of our patients
Collaborate to achieve positive healthcare outcomes
Willingness to learn from others and allow them to learn from you

Selection and Appointment Process

Prospective members must be an active, existing patient or a family member of a patient.
Complete an application and background check.
Will be screened, interviewed and selected by PFAC Co-Chairs or designees.
Will participate in annual mandatory orientation and training.
Once appointed, members will serve for a term of two years.

Meetings and Responsibilities

Council meets 10 months out of the year. Meetings are 60-90 minutes.
At least 50% attendance at meetings is required.
Preparation, engagement and constructive feedback are encouraged.

New User Details

User ID

User ID (verify)

Password

Password (verify)

VOLUNTEER INFORMATION/INFORMACIÓN DEL VOLUNTARIO O VOLUNTARIA

Gender/Sexo

Name prefix/Prefijo

* First Name

Middle Initial

* Last Name

* Date of Birth

* Home Address

* City

* State

* Zip Code

* Primary Phone

* E-mail Address

* Drivers Licence

* State Issued

* SSN

Shirt Size

Language

Additional languages

Ethnicity

Marital Status

EMERGENCY CONTACT INFORMATION

* Primary Contact Name (First,Last)

* Relationship

* Primary Phone

* E-mail

Home Address

City

State

Zip Code

VOLUNTEER INFORMATION

Please select which Patient and Family Advisory Council you are interested in serving on.

Requested site - choose one (1)

Position Category

* Why would you like to be a part of our Patient and Family Advisory Councils at Harris Health?

Please summarize your volunteer and work experience:

* First date available to join council:

Meeting Attendance

EDUCATION AND EMPLOYMENT INFORMATION

Highest Level of Education

School/Major:

Employment Status

Company Name

Current Job Title

Business Experience

PHOTO RELEASE:

As a Harris Health volunteer, I realize that my image may be taken at hospital celebrations and other media events. I give my permission to Harris Health to use my image in any appropriate and related materials that will promote or otherwise publicize my experience at Harris Health.*

BACKGROUND CHECK AUTHORIZATION:

* I authorize Harris Health System to conduct any and all inquiries necessary to determine my acceptability as a volunteer, including a thorough background check. I understand that this background check may include verification of personal and/or employment references, military information or police record inquiries.

* I am 18 years of age or older.

* By checking this box I agree to have Harris Health System conduct a background check.

Please Select

Choose if you have ever been convicted of or been on defferred adjudication for, or are you now either awaiting trial for or on deferred adjudication for, a felony or misdemeanor.

List and explain convictions if any:

CONFIDENTIALITY AGREEMENT:

I agree to use confidential or proprietary information only as needed to perform my volunteer duties. This means I will not access confidential or proprietary information without legitimate need/permission, nor in any way divulge, copy, release, sell, lend, revise, alter, or destroy any confidential or proprietary information belonging to Harris Health System. I understand that I will be automatically dismissed as a volunteer if I do not respect my responsibility for maintaining confidentiality.

If accepted as a Harris Health System Volunteer, I agree to the following:

1. Understand that it is a crime to solicit business for attorneys and/or insurance companies.

* 3. Am donating my services to the hospital district without expectation of compensation and am not to solicit employment while performing my volunteer duties.

* 4. Understand that the Volunteeer & Guest Services Department does not assign volunteers to areas of professional or medical confilicts of interest.

* 5. Will not sell or attempt to sell any goods or services, solicit monetary or in-kind contributions, or collect/distribute petition signatures on Harris Health System premises.

* 6. Understand that, I must never attempt to assess or diagnose any patients, nor shall I attempt to perform any medical procedures (i.e. draw blood, insert an IV and any other procedure that requires a medical license) on patients.

* 8. Understand that the Volunteer & Guest Services Department reserves that right to terminate my volunteer status as a result of: Failure to comply with Harris Health System and departmental policies, rules and regulations; Unsatisfactory attitude, work or appearance/attire; Habitual tardiness and/or absences; and/or any behavior deemed unacceptable by any Harris Health System facility, department supervisor and/or the Volunteer & Guest Services Department.

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