Performance Manager
Application for BIDMC Patient and Family Advisors
1. Name:  
 
First name:
 
Last name:
2. Mailing address:  
 
Number/Street:
 
City:
 
State:
 
Zip code:
3. Contact Information  
 
Email address:
 
Daytime phone:
 
Cellular phone:
 
Evening phone:
4. Best way(s) to contact you: Daytime phone
 
Cellular phone
 
Evening phone
 
Email
 
Postal mail
5. Please provide us with the name and phone number of someone whom we could contact in case an emergency were to occur while you were participating as a Patient and Family Advisor:
   
6. Language(s) you speak:
   
  We are hoping to find volunteers that reflect the diverse experiences of patients and families who use our hospital and clinics. Please answer the following questions regarding your experience at BIDMC.  
   
7. I am or have been: A patient
A family member of a patient
Both patient and family member
   
  Please indicate the number and kinds of visits you and/or your family member have made in the last two years. If you are responding as both a patient and a family member, please fill in both sections below.  
  PATIENT VISITS: Questions 7 - 9  
8. In the last two years, how many inpatient admissions to BIDMC have you had? 0
1
2
3-5
more than 5
9. In the last two years, how many times have you had clinic (outpatient) appointments? 0
1
2
3-5
more than 5
10. In the last two years, how many times have you visited the Emergency Department? 0
1
2
3-5
more than 5
  FAMILY MEMBER VISITS: Questions 10 - 12  
11. In the last two years, how many inpatient admissions to BIDMC has your family member had? 0
1
2
3-5
more than 5
12. In the last two years, how many times has your family member had clinic (outpatient) appointments? 0
1
2
3-5
more than 5
13. In the last two years, how many times has your family member visited the Emergency Department? 0
1
2
3-5
more than 5
14. Within the past two years, what care services have you or your family member used? (check all that apply)  
  Cancer Care
  Cardiology
  Emergency Department
  Gerontology
  GI/Liver
  Intensive Care Unit (ICU)
  Mental Health
  Nephrology/Kidney
  OB/GYN/Childbirth/Neonatal Care
  Opthalmology/Eye Unit
  Orthopaedic
  Primary Care
  Rehabilitation Services (PT/OT/Speech)
  Surgery
  Transplant
  Urology
 
Other, please specify
 
   
15. Please tell us why you are interested in serving as a patient/family advisor and why you feel you would be a good representative for other patients/families?
16. Have you previously served at another organization(s) as an advisor, been an active volunteer committee member or sat on a board of directors? Yes
No
17. If yes, please describe your experience.
18. There are a number of ways to serve as an advisor to BIDMC. Please indicate what opportunities you would be most interested in learning about by checking the boxes to the right.  
  Hospital-Wide Advisory Council: Focus on issues that affect patient care throughout the hospital. (Commitment: 6 meetings per year for a term of 2 years. Evening meetings about 2 hours long.)
  Universal Access Council: Focus on how to improve accessibility and utilization of BIDMC facilities and services. (Commitment: 6 meetings per year for a term of two years.)
  Newborn Intensive Care Unit Council: Focus on issues important to families during and after their baby's NICU hospitalization. (Commitment: 3-4 meetings for a term of 2 years)
  Intensive Care Unit Council: Focus on issues important to patients and families during their time in the ICU. (Commitment: 6 meetings per year for a term of 2 years.)
  Hospital Committees: Join existing issue-specific hospital committees in order to offer a patient/family perspective. (Term and length of meetings varies, depending on the committee. Most meetings are held between 8am and 5pm.)
  Focus Groups and Other Ad Hoc Projects: One-time commitments responding to particular projects or questions.
   
  Please note: BIDMC provides parking vouchers and food during mealtimes for meetings at the hospital.  
  Click "Submit" below to send your application.  
          



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