Community Engagement Advisory Network (CEAN)
Patient & Public Involvement
The Community Engagement Department at Vancouver Coastal Health supports a variety of
opportunities for members of the public to become involved in the advising and planning of
health services. To ensure that we involve you in ways that most interest you, please
complete the form below. We will contact you within two weeks to talk about our current and
future activities.
NOTE: Please fill out the application form, sign it and email it back to us at: ce@vch.ca. Upon receipt
of your emailed form, we will call you to set up a brief interview.
Many thanks for your interest and future support.
Today’s Date:
Name:
Address:
Home Phone:
Cell Phone:
Email Address:
Fax Number:
Postal Code:
Would you like to share your e-mail address with other CEAN members?
Work Phone:
YES
NO
Please tell us which of the following describe you? (Please tick all that apply)
I have been a patient or resident in a VCH facility over the past 5 years
I am a family member/loved one of a patient (please specify relationship to patient):
I am a representative of partner agency (please specify position and agency):
I volunteer with other community, non-profit groups (please list):
I have been Involved with other VCH advisory committees (please list committee name(s) and dates):
Other (please specify):
Please tell us more about yourself.
Why are you interested in patient/public involvement with healthcare services?
Please tell us about your connections to (and/or work with) community groups and networks (e.g. faith groups;
online networks; neighbourhood, student or professional associations, etc.)
What do you hope to gain from your experience with CEAN?
How did you hear about CEAN?
Newspaper
Internet Search
Poster/Flyer
Radio
Friend
Other
Television
Conference/Health Fair
E-mail
VCH Community Engagement - Patient & Public Involvement
Jan 2014
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I am interested in the following areas of healthcare:
Seniors’ services
Services for the Disabled
Paediatric/Child Health
Palliative/End-of-Life Care
Heart/Cardiac services
Lung/Respiratory services
Mental Health services
Addiction services
Diabetes services
Stroke services
Emergency Dept. services
Other (please specify):
I would like to be involved in the following way(s): (Please tick all options that interest you)
I would be interested in acting as an advisor on the content and user-friendliness of patient information materials
Yes
No
I would be interested in joining a patient reference group or advisory committee
Yes
No
I would reply to questionnaires or surveys that were sent to me about health services
Yes
No
What times would you normally be available for these activities? (Please tick all that apply)
Weekdays:
Weekends:
Morning
Morning
Afternoon
Afternoon
Evening
Evening
Vancouver Coastal Health asks that we gather some demographic information about our CEAN
members, to demonstrate representation of our diverse region. Please tell us your:
Age Range:
Gender:
under 19
50 – 59
19 – 29
60 – 69
30 – 39
70 – 79
40 – 49
80 +
Male
Female
Ethnicity/Culture:
Transgender
South Asian (e.g. India, Pakistan, Sri Lanka, Bangladesh)
Asian (e.g. Korea, China, Vietnam, Japan)
Aboriginal, First Nations, Metis
Black, African-Canadian or Caribbean-Canadian
South or Central American
Caucasian, European
Do you speak and/or write languages other than English?
Yes
No
If you answered YES, which language(s)?
Signature: ________________________________
Date: _____________________
Thank you again for your interest and future support.
A staff member of our department will get in touch with you within two weeks.
If you have any questions or would like to speak to someone in person,
please call 604-714-3779
VCH Community Engagement - Patient & Public Involvement
Jan 2014
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