Patient Family Experience Council Interest Form - Self Regional Healthcare

PFEC Interest Form

Thank you for your interest in the Patient Family Experience Council.

Please complete this form if you are interested in becoming a Self Regional Healthcare Patient Family Experience Council Volunteer Member.

Once you've complete the form, click the submit button at the bottom. Interested candidates will be contacted and an application will be mailed. Please allow two weeks for this process. We are not able to place all applicants into the program. If you are not selected for membership on the Patient Family Experience Committee, there may be other focus group opportunities that we may engage you in.

First Name*
Middle Name*
Last Name*
Date of Birth*
Address*
Street Address Address Line 2 City State ZIP Code
Home Phone*
Work Phone
Cell Phone*
Email Address*
Connection
Please indicate if you are (or have been) one of the following:
- Patient of SRH (Self Regional Healthcare)
- Family Member of SRH Patient
- Bereaved Family Member
- Patient of SRH Physician Practices (formerly SMG Self Medical Group)
Relationship to Patient
If you selected "Family Member of SRH Patient" above, what is your relationship to patient?
SRH Physician Practices Patient
If you selected "Patient of SRH Physician Practices" above, who is your Doctor and at what Practice?
Statement of Understanding*
I certify that all statements made in this application are true. I understand that the Self Regional Healthcare reserves the right to accept or reject my application in its sole discretion.

I understand that volunteers must be at least 18 years of age (and age 21 in some areas of the medical complex) for our adult program.

I understand this commitment involves monthly meetings that require my attendance.

I understand that I will be required to present my immunization records to the Employee Health Office in order to be "cleared" to volunteer.

I understand that I will be required to have a health screening (free of charge) at Employee Health Service.

I will be required to provide an oral history of chicken pox and written verification from my personal physician of: two MMR vaccines (measles, mumps and rubella), a *PPD skin test within 3 months, and a tetanus shot within 10 years.

Volunteers must provide proof of Hepatitis B vaccination.

By checking "I Agree" below, I agree to a criminal background check and to a commitment of two years of service on the Patient Family Advisory Council.
- I Agree