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.

Preferred Method of Contact
Best Time to Reach You
Age
Languages Spoken
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 3 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 inmost (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. You will be required to pass a criminal background check, submit immunization records and receive any necessary immunizations, undergo HIPAAtraining and sign a confidentially agreement. If you are unable to fulfill these requirements, you will not be eligible to serve on the Patient and Family Advisory Council.

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. All information contained on this form is considered confidential and is intended for use only by RUSH Copley.
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