Duke Children`s Family Advisory Council Membership Application

advertisement
Duke Children’s Family Advisory Council Membership Application
Name: _________________________________________________________________________________________
Mailing Address: _________________________________________________________________________________
City: ________________________________________ State: ____________________ Zip Code: _________________
Telephone: Home: ____________________Work: ______________________Cell:_____________________________
E-Mail Address: __________________________________________________________________________________
Name(s) and age(s) of Children: _____________________________________________________________________
Your relationship to the Children: ____________________________________________________________________
Have any of your children been hospitalized before?_____________________________________________________
If yes, why and for how long? _______________________________________________________________________
Which unit(s) have your children received care (PICU, PCICU, ICN, 51, 52, 53, 77P, another
hospital)?________________________________________________________________________________________
Have any of your children been in the hospital more than once?____________________________________________
Have your children received care at any other hospital? Yes ____
No ___
If so, which hospitals? _______________________________________________________________________________
_________________________________________________________________________________________________
Are all of these children currently living?________________________________________
If no, would you be willing to share your experience with us?________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
___________________________________________________________
Have you used any outpatient services at Duke?
Yes ____
No ____
Age(s) of children who are cared for by the clinics or outpatient services including the Emergency Department and the
Valvano Day Hospital:
__________________________________________________________________________________________________
Which services or clinics were used and when?
__________________________________________________________________________________________________
__________________________________________________________________________________________________
___________________________________________________________
Have you ever been on a family advisory council before? Yes_____ No_____
If so, where? _______________________________________________________________________________________
Who recommends you for the Family Advisory Council?
Name_________________________________
Phone number and/or email_____________________________
Why would you like to be on the Family Advisory Council?
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
_________________________________
What experiences or strengths would you bring to the Family Advisory Council?
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
Please share any additional information about yourself.
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
Please return this completed application to Emily Patterson
c/o Duke Children’s Family Advisory Councils
DUMC Box 2739
Durham, NC 27710
Or
[email protected]
Download