PFAC Application

PFAC Application

Name*

Enter Complete Address*

Example: 123 Rome Street, Carrollton, GA 30110

Email Address*

Preferred Phone Number*

May we text you at the number above?*

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Preferred Time of Contact*

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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.

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

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I am the*

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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?*

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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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