CHNOLA PFAC Volunteer Application

CHNOLA PFAC Application Form

Check which one applies to you:

* Family/last name

* First name

Middle Initial

* DOB

* Address Line 1

Address Line 2

* City

* State

* Zip/postal

Phone (Home)

* Phone (Mobile)

Phone (Business)

* E-mail

Emergency Contact

* Contact name

Emergency Phone (Home)

Language

Additional languages

Will you allow your contact information to be shared with other committee/advisory council members?

I am/was:

My care is/was provided by:

Check all that apply: (copy)

Hospitalization (Inpatient)

Clinic Visit (Outpatient)

Both Inpatient and Outpatient

Emergency Department Care

Other programs, departments or services

The dates of my active care experience at Children's Hospital New Orleans Include:

Check all that apply:

Within the past 5 years

More than 5 years ago

More than 10 years ago

Within the past two years, what care services have you or your family member used?

We are looking to our Council members to have a diversity of experience with Children's Hospital and appreciate your sharing any information. Please be assured that this information is private and will be maintained as CONFIDENTIAL.

Check any that apply:

Auto-Immune

Blood and Lymphatic Defects

Cancer

Cardiology

Chest/Pulmonary Ear, Nose and Throat

Endocrinology/Diabetes

Eye

Gastroenterology/GI

Genetics and or Birth Defects

Infectious Disease

Intensive Care Unit (ICU)

Mental Health Nephrology/ Kidney Neurology/ Neurosurgery

Nutrition

Orthopedic Rehabilitation

Skin and Connective Tissues

Surgery

Transplant

Urology

Other ____________________________________________________

Times when you can engage in PFAC work: (check all that apply)

Daytime

Evening

Weekend

I would be interested in helping with (identify all your interest areas):

Developing/reviewing educational materials to improve the patient and family experience.

Planning for the hospitalization (inpatient) care experience for children

Planning for the emergency care experience.

Planning for the clinic (outpatient and ambulatory) care experience.

Planning for the oncology care experience.

Planning the design of systems of care and facilities for the emergency experience.

Educating medical students and residents, new employees, and other staff about the experieince of care and effective communicaiton support.

I would be interested in helping as:

Virtual Volunteer

A virtual volunteer doesn't do any inhouse activities with patients and familiers.

All meeting and participation are virtual. Patient rounding will be done over the phone.

Requirements that must be completed:

Online PFAC Volunteer Application
PFAC Volunteer Contract
Background Check

In house Volunteer

Requirements that must be completed:

Online PFAC Volunteer Application
PFAC Volunteer Contract
Background Check
Provide documentation of Required Immunizations and Health Screenings. A list of each immunization and health screening will be provided for you in another email. An appointment with Empoyee Health can be set up if you need to get a drug screening, TB/PPD, MMR/PPD Test, MMR/Varicella Titer Test, Flu shot, or tdap immunizations

* Why would you like to serve as a Children's Hospital Patient and Family Advisory Council member?

* If you have served as an advisor, been an active volunteer comittee member, or done public speaking for other programs or organizations, please briefly describe this experience

* Tell us about your family's healthcare experience at Children's Hospital. What would you have improved about this experience? What impressed you about the experience?

* Is there anything else you would like us to know?

Do you know other individuals and/or families who have experienced care at Children's Hospital who might be interested in serving as advisors? Please call them for us or list their name(s) and phone number(s) here:

Please identify which PFAC you are interest in volunteering with:

General PFAC

Heart Center/ Cardiology

Neonatal Intensive Care Unit/ NICU

Hematology / Oncology

After you complete and submit your PFAC online volunteer applicaiton, please notify Kristie Rozands to let her know, her email address is kristie.rozands@LCMChealth.org.