PFAC Application

You are submitting this Form in a secure and confidential environment.

Name

Enter Complete Address

Example: 123 Rome Street, Carrollton, GA 30110

Email Address

Preferred Phone Number

May we text you at the number above?

Preferred Time of Contact

Have you ever been convicted of a crime, plead guilty, nolo contender or had adjudication withheld?

A criminal conviction will be considered according to the seriousness, nature of the offense, time that has lapsed, and rehabilitation.

Do you or a loved one receive services with Tanner Health?

I am the

Please tell us why you are interested in joining the Patient and Family Advisory Council

Please describe any other committee experience you have had either at schools, in the community, etc and list organizations and activities in which you have been active.

Are you comfortable speaking in a group setting?

What specific skills could you bring to the PFAC?

What are some of the behaviors and practices performed by team members that improved your experience(s) within Tanner Health?

What are some behaviors and practices performed by team members that you believe should have been handled differently?

What experience(s) as a patient, caregiver or family member have you had?

Examples: childbirth, Emergency Room visit, trauma, end of life of a loved one, etc.

If you are comfortable sharing, do you have any special needs/restrictions you would like us to be aware of when reaching out to arrange an interview?

Are you comfortable with participation in both in-person and virtual meetings?

Virtual meetings are held on the Microsoft Teams platform

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