Volunteer Resources | Hamilton Health Sciences

Thank you for your interest to join Hamilton Health Sciences (HHS) as a Patient and Family Advisor (PFA). As a Patient and Family Advisor your insights will help to identify what matters most to our patients and their families in their health care experience. Please complete this form to be considered as a candidate for a Patient and Family Advisor position.

Hamilton Health Sciences | Patient and Family Advisor Program

HHS | Patient and Family Advisor
Requested site
Basic Information
First name
Last name
Home Address
Address
Apt/Unit
City
Province
E-mail
Zip/postal
Home phone
Work phone
Mobile phone
The following questions will help us to get to know you better:
Are you a...
Patient
Other (please specify)
Family member or caregiver of a patient
When was your experience at Hamilton Health Sciences
Currently
3-5 years ago
1-2 years ago
More than 6 years ago
Please indicate the location(s) you or your family member have used (check all that apply):
Hamilton General Hospital
Ron Joyce Children's Centre
St. Peters Hospital
Juravinski Hospital and Cancer Centre
Urgent Care Centre
McMaster Children's Hospital
McMaster University Medical Centre
West Lincoln Memorial Hospital
Which areas provided care to you or your family member? Check all that apply:
Nuclear Medicine (e.g.: MRI, PET scan, etc.)
Diagnostic Imaging (e.g.: CT, ultrasound, x-ray, etc.)
Outpatient (Ambulatory) Clinic
Emergency Department
Inpatient Unit
Rehabilitation Services (e.g.: Occupational Therapy, Physiotherapy, Speech, etc.)
Laboratory Services (e.g.: Bloodwork, etc.)
Other (please specify):
How did you hear about Hamilton Health Science's Patient & Family Advisor Role?
Please tell us why you are interested in becoming a Patient and Family Advisor
Do you have experience as a member of a committee either through paid work or as a volunteer?
No
Yes
If yes, please tell us about the most recent committee(s) and your role(s):
How do you think your experience (including work, volunteer and health care experiences at Hamilton Health Sciences) and skills will help you as a Patient and Family Advisor? Please share examples of your experience and/or skills
We want a diverse team of Patient and Family Advisors with a wide-range of personal experiences and viewpoints to reflect all of the communities we serve. What aspects from your background would add to the Patient and Family Advisor Program? (Examples: activities within your community, new or long-time patient at HHS, language, cultural backgrounds, etc.)
Please select the time(s) of day you are available to participate in Patient and Family Advisor activities. Check all that apply:
Morning (7 am - 12 pm)
Afternoon (12 pm - 5 pm)
Evening (5 pm - 8 pm)
Weekend
Other (please specify):
There are many ways to participate as a Patient and Family Advisor. Please check the area(s) that are of interest to you:
Virtual Opportunities (e.g. Developing and reviewing education materials, completing surveys, reviewing and providing input on documents)
Committee work (i.e. Regular monthly meetings - approximately 2hrs)
Focus groups or strategic planning sessions
Short-term projects or working group focused on making improvements to specific healthcare services (approximately 1-2 hours per month)
Other Research interests:
Confidentiality
Patient's medical information is strictly confidential and must never be discussed unnecessarily with others.
As a member of HHS, all information concerning patients, family, visitors and staff will be held in confidence.
Disclosure of confidential information shall be subject to discplinary action up to and including discharge.
Agree
Disagree
Emergency Contact
Contact name
Phone
Electronic Signature:
Date: