All fields with an asterisk (*) are required. Thank You The form was submitted successfully. 2024-CAP-Portsmouth Regional Hospital-Patient and Family Advisor Application-PI Please fill in a valid value for all required fields Please ensure all values are in a proper format. Are you sure you want to leave this form and resume later? Are you sure you want to leave this form and resume later? If so, please enter a password below to securely save your form. Save and Resume Later Save and get link You must upload one of the following file types for the selected field: There was an error displaying the form. Please copy and paste the embed code again. Apply Discount You saved with code Submit Form Submitting Validating There was an error initializing the payment processor on this form. Please contact the form owner to correct this issue. Please check the field: Fields I or a family member have been treated at Portsmouth Regional Hospital as an inpatient or received outpatient care within the past two years.* Yes No Please do not apply- To be eligible to serve as a patient and family advisor, your or a family member must have been treated at Portsmouth Regional Hospital as an inpatient or received outpatient care within the past two years. Name* First Name* Last Name* Address* Address Line 1 Address Line 2 City Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Guam Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Puerto Rico Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virgin Islands (US) Virginia Washington West Virginia Wisconsin Wyoming Armed Forces (the) Americas Armed Forces Europe Armed Forces Pacific Army Post Office (U.S. Army and U.S. Air Force) Fleet Post Office (U.S. Navy and U.S. Marine Corps) State ZIP Code Home phone* Cell phone* Email* Preferred method of contact* Home phone Cell phone Email What language(s) do you speak?* We recognize that our patient and family advisors have busy lives. How much time are you able to commit to being a patient and family advisor?* Less than one hour per month One to two hours per month Three to four hours per month More than four hours per month As an advisor, you will have the opportunity to work on a range of issues. Which of the following are most interest to you? (Check all of your interest areas.)* Help improve overall patient expereince. Help develop or review informational materials for patients and family members. Help improve patient safety and the prevention of medical errors. Help improve the patient and family role in care decision-making. Help improve the hospital facilities (for example, patient care areas or family resource room). Help educate or train hospital staff and clinicians. Review procedures and provide input to improve the hospital admission process. Provide input as we implement bedside shift report between nurses. Review procedures and provide input to improve transitions in care (for example, between hospital units or discharge from hospital home). Other issues Please describe* The following information will help us get to know you better. Why do you want to become a patient and family advisor?* Briefly describe any experience you may have as an advisor, an active volunteer or public speaker.* If you or a loved one have received care at Portsmouth Regional Hospital, please tell us about your experience. What went well or made a positive impression? What could have been done differently or better?* Our patient and family advisors reflect the diversity of the patients and families we serve. Share anything about yourself that you think would add to the diversity of our team of advisors.* General Internet communication is inherently not secure. DO NOT send data considered confidential or private in nature on this form. (e.g., Social Security Numbers, Diagnosis Information, Credit Card Numbers, etc.) Previous← Next→ Enter your save and resume password Cancel Confirm
