Patient & Family Advisory Council (PFAC) Membership Application

Patient & Family Advisory Council (PFAC) Membership Application

Thank you for your interest in serving on the Patient & Family Advisory Council (PFAC) at Good Samaritan. PFAC members partner with Good Samaritan representatives to improve the patient experience, safety, communication, and quality of care. Your voice matters!
SECTION 1: Personal Information
Full Name*

First NameLast Name
Preferred Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*
Please enter a valid phone number.
Email*
example@example.com
Preferred Contact Method

PhoneEmailText
SECTION 2: Patient / Family Experience
Please check all that apply*

I am a former patient at Good SamaritanI am a family member/caregiver of a patientI have received care at Good Samaritan
I have received care at Good Samaritan within the last*

12 months2 years3+ years
SECTION 3: Availability

PFAC meets monthly, typically the first Thursday of every month from 3:00pm – 4:00pm. Along with attending the monthly PFAC meeting, your chosen Good Samaritan Committee/Council will also meet regularly (days, times, and frequency vary depending on which you choose).
What days are you generally available?*

All WeekdaysMondayTuesdayWednesdayThursdayFriday
What time of day are you generally available?*

MorningsAfternoonsEvenings
SECTION 4: About You

Please answer the following questions.
Why are you interested in joining our PFAC?*
Describe an experience at Good Samaritan that motivated you to apply (positive, challenging, or both).
What strengths, skills, or perspectives would you bring to the council? (e.g., communication, empathy, advocacy, lived experience, community involvement)
How comfortable are you sharing your experiences and providing constructive feedback?
Have you served on any committees, volunteer groups, or advisory councils before?*

YesNo
Please describe:*
SECTION 5: Background Screening

PFAC members may be subject to standard onboarding, which includes: Background check, Confidentiality/HIPAA agreement, Orientation – One time attendance at one of our organization orientations (full day on a Monday)
Are you willing to complete these steps?*

YesNo
SECTION 6: Emergency Contact
Emergency Contact Name*

First NameLast Name
Relationship*
Phone Number*
Please enter a valid phone number.
SECTION 7: Signature
I certify that the information I have provided is accurate. I understand that participation is voluntary, and I agree to uphold the mission, vision and values of Good Samaritan.
Signature*

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Patient & Family Advisory Council (PFAC) Membership Application

SECTION 1: Personal Information

SECTION 2: Patient / Family Experience

SECTION 3: Availability

SECTION 4: About You

SECTION 5: Background Screening

SECTION 6: Emergency Contact

SECTION 7: Signature