Outer Banks Health (OBH)Patient and Family Advisor Application

Outer Banks Health (OBH)

Patient and Family Advisor Application

Thank you for your interest in the Patient-Family Advisor role. Please answer the questions included here. We do not discriminate on the basis of race, religion, gender or gender identity, national origin, age, or ability.

The OBH Patient and Family Advisory Council (PFAC) invites you to share your lived experiences as a patient, family member, and/or team member to support Patient- and Family-Centered Care throughout the ECU Health system.

If you have any additional questions, please contact OBHVolunteers@theobh.com

Volunteer Services Application

All PFAC members are official Outer Banks Health volunteers.

If you have not already, please click here to complete the OBH Volunteer application. Under “Assignment Preference," please select, “Patient & Family Advisor.” Once complete, please return and complete the PFA Application below.

Name*

Preferred Pronouns

select all that apply

she/her

he/him

they/them

other (please state)

Date of Birth*

Please use the following format: 00/00/0000

Address*

Please include City, State, and Zip code

Phone *

Please provide your preferred contact

Phone

E-mail *

Provide an Emergency Contact*

Include Name, Relationship, and Phone

Have you ever been or currently employed by OBH?*

Select

Have you or any of your family member(s) received services at any ECU Health facilities including OBH?*

Select or enter value

List the areas where you have patient/family experience:*

Why are you interested in volunteer service at the hospital?*

If you are a current volunteer, what has been the most rewarding part of your experience so far?

Are there specific areas at OBH where you believe we can enhance our efforts? Where can we grow as a leader in both the health care and Outer Banks communities?*

Thinking of your life, what makes you most proud?*

Please share one of your goals for this year (personal or career).*

Do you have any experience working or volunteering in a health care facility, or receiving care for yourself or as a caregiver? If so, what special area did you give or receive care?*

(Example: Surgery, Cancer Center, Children’s Hospital, Women’s Services, Palliative Care, etc.)

Select your area of interest. Check all boxes that describe your interest.*

Select or enter value

Is there anything else you wish to share?

If you are an employee of OBH, please answer the additional question below:

How does (or could) the PFAC relate to your health care career?

Living Our Values Everyday (LOVE)

IC-EAST Values and Behaviors

Integrity: Always honest, sincere and ethical.

Compassion: Always caring, relational, and respectful.

Education: Always curious, growing and innovative.

Accountability: Always responsible, dependable and proud.

Safety: Always intentional, thoughtful and focused.

Teamwork: Always collaborative, supportive, and inclusive.

Terms and Conditions*

I hereby apply to become a patient/family advisor at ECU Health, to abide by my commitment to:

• Maintain patient privacy and confidentiality

• Support the ECU Health mission

• Actively participate in improving care for all patients and families

• Listen to different opinions and share ideas and viewpoints

• Use my lived experience in health care to improve current and future experiences

• Advocate for and listen to other patients, families, team members, and community members

• Support positive relationships with our health system and members of the community

ADVISOR CONFIDENTIALITY STATEMENT

ECU Health has a legal and ethical responsibility to safeguard the privacy of all patients and protect the confidentiality of their health information. In the course of my assignment at ECU Health, I may come into possession of confidential patient information, even though I may not be directly involved in providing patient services. I understand that such information must be maintained in the strictest confidence.

As a condition of my assignment, I hereby agree that I will not at any time during or after my assignment disclose any patient information. When patient information must be discussed within the course of my assignment, I will use discretion to ensure that such conversations are not held in a public place or with individuals or groups who are not current ECU Health employees or Patient and Family Advisors (PFA) directly involved in the assignment. I further agree to maintain the confidentiality of ECU Health proprietary information and other information which I have obtained by virtue of my service as a PFA. I agree to avoid releasing or disclosing any such information to third parties, including members of the media, and all others not employed or actively serving as a PFA with ECU Health.

I agree to comply with ECU Health’s behavior standards (provided in this application) and with all requirements to maintain active volunteer status. If I fail to do so, I will be placed on inactive status and unable to serve until requirements are met, and I may be removed from my role permanently. I understand that completion of this application does not guarantee acceptance as a Patient & Family Advisor. I will be notified of the status of my application by ECU Health Volunteer Services and/or the ECU Health Office of Experience. I attest that all information provided in this application is true and accurate.

Selecting the check box below represents by agreement and commitment to comply with the statements above.

Send me a copy of my responses

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