Patient and Family Advisory Council for Quality and Safety (PFACQS) Questionnaire

* required information

Applicant Information
Name *
E-mail Address

Phone* - -
Steet Address*

City* State* ZIP*
Please tell us about your experience at MedStar Health
Have you ever been hospitalized at MedStar Georgetown University Hospital for more than 24 hours?*   

If your answer is YES, how long was your longest hospitalization?


Have you ever been a caregiver for a patient who was hospitalized at MedStar Georgetown University Hospital for more than 24 hours? *
  

If your answer is YES, how long was the longest hospital stay of the person you were caring for?


How many times have you or a person in your care been hospitalized at MedStar Georgetown University Hospital in the last three years? *

How would you describe your hospital experience at MedStar Georgetown University Hospital? *

 

What did the hospital do well during your stay or your loved one's stay?*

 

What could the hospital have done better?*

 
Please tell us more about you
Do you volunteer in your community?*     
 

If so, for which organizations?


Is English your first language?*   

If no, what is your primary language?

Do you feel comfortable working in groups, speaking up and providing input? *
  
Eligibility Criteria
Are you able to attend meetings at MedStar Georgetown University Hospital during weekday evenings?*   

Are you willing to take the necessary immunizations to serve on the Patient Family Advisory Council for Quality and Safety?*   

Are you willing to sign an agreement promising not to disclose confidential information given to you in your role as a member of the Patient Family Advisory Council for Quality and Safety?*   

Are you willing to undergo a background check?*