Patient and Family Advisory Council

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Full name:
Email:
Phone number:
Street address:
City:
State:
U.S. ZIP code:
Date of Birth:
Have you ever been employeed, volunteered or applied previously at Merrimack Health? If yes, provide title and dates:
I am currently a:	Patient Family member Community representative
How did you learn about our PFAC opportunities?:
Which campus PFAC group are you interested in assisting with?:	Lawrence Hospital Methuen Hospital (Please select one)
Tell us about your experience with Merrimack Health.:
What impressed you about your experience?:
What would you have improved about the experience?:
Why do you want to be involved in the Patient and Family Advisory Council? :
Is there anything else you would like us to know?:
Please share your interest by checking items to inquire of Patient Family Advisor (PFA) opportunities.:	Behavioral health/substance abuse Bereavement Board of Directors Care transitions Code of conduct Community benefits Critical care Culturally competent care Discharge delays Diversity and inclusion Drug shortage Eliminating preventable harm Emergency Deparment patient/family experience improvement Ethics Institutional Review Board (IRB) Lesbian, Gay, Bisexual, and Transgender (LGBT) - Sensitive Care Patient care assessment Patient education Patient and family experience improvement Pharmacy discharge script program Quality and safety Quality/performance improvement Surgical home A PFA is a person who brings their experience as a patient or family member to the decision-making table. An Advisor looks at the big picture through the lens of their own experience. Our hospital may/may not have the listed hospital-wide committees, projects, task forces or work groups.
Please type your name in this box after reading the disclosure.:	By submitting this application, I verify that the information on this application is true to the best of my knowledge. I understand that false statements made as part of this application will be considered cause for dismissal. I understand that if I am accepted as a PFAC advisor, I will not be paid for my services and agree to abide by the guidelines of the PFAC program.

Patient and Family Advisory Council

Patient and Family Advisory Council (PFAC)

Do You Want to Help Make a Difference at Lawrence Hospital?

Help Us Make Every Patient Experience the Best It Can Be!

What Is the Patient and Family Advisory Council?

How to Contact Us

Interesting in Joining PFAC? Fill Out an Application