Patient Family Advisory Council Application
Full Name
Address
Email
Phone number
Phone
Have you ever been hospitalized at Logan Health for more than 24 hours?
Yes
No
How long was your longest hospitalization?
Have you ever been a care-giver for a patient who was hospitalized at Logan Health for more than 24 hours?
Yes
No
How long was the longest hospital stay of the person you were caring for?
How many times have you or a person you take care of been hospitalized at Kalispell in the last three years?
How would you describe that hospital experience?
What did the hospital do well during your stay or your loved one's stay?
What could the hospital have done better during your stay or your loved one's stay?
What would you like the hospital to learn from your stay or your loved one's stay?
Please share any additional feedback you may have
Do you volunteer in your community? If so, for which organizations?
Do you feel comfortable working in groups, spreaking up and providing input?
Is english your primary language?
Yes
No
What is your primary language?
Are you able to attend meetings in Kalispell during weekday evenings?
Yes
No
Are you willing to sign an agreement promising not to disclose confidential information give to you in your role as a member of the Patient Family Advisory Council?
Yes
No
Are you willing to undergo a background check?
Yes
No
Send me a copy of my responses
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