Rush Copley's Patient & Family Advisory Council Application

Please complete and submit the below application if you are interested in serving on the Patient and Family Advisory Council (PFAC) as an advisor. The PFAC will provide hospital administrators, physicians and staff with suggestions and constructive feedback on a variety of patient and family issues concerning patient care at Rush Copley and its offices. Topics may be introduced by Rush Copley staff members, as well as Council members.

The PFAC will meet as a group approximately six times each year with various hospital staff. Patient and Family Advisors will serve a two-year term.

Pronouns
Is this a cell phone?
Is it OK for us to text you?
Preferred Method of Contact
Best Time to Reach You
Age
Are you currently/have you been an employee of Rush Copley Medical Center?
Are you currently/have you been a volunteer at Rush Copley Medical Center?
Languages Spoken

Emergency Contact Information

Which of the following best describes you?
Highest Level of Education
Have you ever served on an advisory council or committee?
Have you been a patient at Rush Copley in the last three years?
Has someone close to you/in your care been a patient at Rush Copley in the last three years?
Are you able to make a commitment to participate in most (at least 9 out of 12) monthly meetings?
Are you able to attend meetings virtually if necessary?

Conditions of Volunteer Services (Please read before submitting):

We will contact you by phone or email if you are selected for an on-site interview to learn more about your interests, and discuss the opportunity to become a member of the Patient and Family Advisory Council.

In order to participate, you must meet our volunteer requirements. 

  • Be at least 18 years old
  • Pass a criminal background check
  • Complete an initial 2-step TB test (performed free of charge by Rush Copley Family Medicine Center)
  • Provide vaccination records for MMR, Varicella, and Tdap or have a blood titer drawn to verify immunity (if needed, the blood titer and any vaccinations will be provided free of charge by Rush Copley Family Medicine Center)
  • Receive an annual flu shot
  • Attend an onboarding training meeting offered through Volunteer Services
  • Sign an agreement to abide by HIPAA
  • Sign a confidentiality agreement
I certify that the statements made in this application are true and correct and have been given voluntarily. I understand that I will not be paid for my services as a volunteer member of the Patient and Family Advisory Council. I agree to abide by the guidelines of Volunteer Services, to respect patient confidentiality, and to uphold the standards of Rush Copley. I have read and agree to the volunteer requirements above. All information contained on this form is considered confidential and is intended for use only by Rush Copley.
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