Webform Patient and Family Advisory Council Application We welcome patients and family members to provide feedback on their health care experiences and have created a variety of advisor roles. Your participation to review policy, processes, communication materials, physical environment, quality improvement activities, and safety efforts can lead to improved service delivery and an enhanced patient experience. Thank you for your interest in becoming an Experience Advisor at Munson Healthcare Manistee Hospital. This application is the first step to get to know you, as well as a little about your experiences here at Manistee Hospital. PARTICIPANTS MUST BE 18 YEARS OLD OR OLDER AND HAVE RECEIVED CARE FOR THEMSELVES OR A FAMILY MEMBER AT MANISTEE HOSPITAL IN THE PAST YEAR. First Name Last Name Email Address Telephone Address Line 1 Address Line 2 City State - Select -AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming Zip Are you 18 years old or older? No Yes Have you or a close family member received care at Manistee Hospital or its physician practices in the last year? No Yes Have you or your family had health care experiences with Manistee Hospital that you would feel comfortable in discussing and helping us improve or expand? Please indicate where those services were received. Check all that apply. Cancer & Infusion Services Emergency Room Inpatient Medical/Surgical Unit Laboratory Services Obstetrics / Maternal & Newborn Center Other Service(s) Outpatient Clinic Outpatient Surgery Radiology Services If you checked Outpatient Clinic above, which practice(s)? If you checked Other Service(s) above, what service(s)? What would you like us to know regarding your past experience(s) receiving care at Manistee Hospital? Is there any other information you would like to share with us in considering your application? Skills, expertise, past experiences, availability, etc. Tell us why you are interested in being an Experience Advisor. Please include the name of a Manistee Hospital staff member who knows you (doctor, nurse, tech, administrator, etc.) Include his or her department. Areas of Interest The following list reflects the many ways that patients, family and community members can be involved in our Patient Community Engagement Committee efforts. - Committee Member: Membership on the Patient Community Engagement Committee. The work will include regular meetings and might include activities such as helping to design or improve a new or current program, service, policy or process. This also involves working closely with different clinical and non-clinical staff. Your role will be to bring/represent the patient or family perspective. - Focus Group Participant: Occasionally we bring groups of patients or family members together to hear perspectives and ideas on a specific topic. This is a time-limited experience, sometimes only once. - Communication Reviewer: Gaining the user's perspective when drafting brochures, patient education materials, websites, policies, newsletters, and marketing materials is critical. This work can sometimes be done electronically and from your own home. Requests for this assistance are variable. - Experience Sharing: Our Experience Advisors are often asked to share their personal healthcare experiences as a way for us to learn what was helpful and what was not. Experience may be shared at new employee orientation, educational seminars for professionals, or department or committee meetings. We will provide you with an orientation and training depending upon the activity that interests you and what opportunities exist. Please check your areas of interest in our Patient Community Engagement Committee. Committee Member Communication Reviewer Experience Sharing Focus Group Participant Optional These questions are optional but will help us make our committees as diverse as possible. Please check all that apply. Ethnicity African American Asian Hawaiian or Other Pacific Islander Latino or Hispanic Latino/Non-Hispanic Native Alaskan or American Indian Other White If you checked Other above, please list ethnicity Primary language spoken Religion Do you have any physical challenges? Check all that apply. Ambulation Hearing Other Sight Speech If you checked Other above, please list your physical challenge(s). Age range 18-24 25-29 30-49 50-64 65-79 Birth date Gender Female Male Non-binary This question is for testing whether or not you are a human visitor and to prevent automated spam submissions.