PFAC Application

Thank you for your interest in joining Guadalupe Regional Medical Center’s Patient and Family Advisory Council! Council members are essential partners in the Medical Center's mission to provide excellent patient- and family-centered care.

A Patient and Family Advisory Council (PFAC) is a collaborative group of patients, family members, caregivers, and healthcare professionals dedicated to improving the quality, safety, and patient-centeredness of healthcare services. By sharing personal experiences and insights, PFAC members provide valuable feedback to enhance policies, programs, and overall patient care. They work alongside healthcare providers to identify opportunities for improvement, advocate for patient needs, and promote meaningful changes that foster a more compassionate and effective healthcare environment. Through active participation in decision-making, quality initiatives, and educational efforts, PFACs help create a culture of transparency, engagement, and continuous improvement, ensuring that healthcare services align with the needs and expectations of the patients and families they serve.

If you have any questions or would like more information about GRMC’s Patient and Family Advisory Council (PFAC), please email pfac@grmedcenter.com.

Please fill out the secure application below.

General Information

By checking this box, I affirm I am 18 years of age or older.(Required)

By checking this box, I affirm I am 18 years of age or older. (Required)

Name(Required)

First Name

Name

Middle Name

Name(Required)

Last Name

Gender(Required)

Male

Female

Choose not to respond

I am fluent in the following language(s): (check all that apply)(Required)

English

Spanish

Other

By checking this box, I acknowledge that I am comfortable reading and conversing in the language(s) selected.(Required)

By checking this box, I acknowledge that I am comfortable reading and conversing in the language(s) selected.

Highest Education Level(Required)

High School

High School Diploma or Equivalent (GED)

College Coursework / College Degree

Post Graduate Education

Occupation

Address 2(Required)

Address 2

Address 2(Required)

What county do you live in?(Required)

Home Phone (Required)(Required)

Cell Phone (Required)(Required)

Email Address (Required)(Required)

Preferred Method of Contact(Required)

Home Phone

Cell Phone

Text

Please respond to the questions below to help us get to know you better

I am a:(Required)

Patient

Family member/Loved one of a patient

Caregiver of a patient

Hospital Employee or Volunteer

When was your/your loved ones experience at GRMC? (check all that apply)(Required)

Which unit of service was provided for you or your loved one? (check all that apply)(Required)

Do you use the GRMC Patient Portal?

Yes

Why do you want to join the Patient and Family Advisor Council?

Emergency Contact Information

Name(Required)

First Name (Required)

Last Name (Required)

Address 2

Address

Home Phone

Cell Phone (Required)(Required)

Relationship (Required)(Required)

References

Name(Required)

First Name (Required)

Name(Required)

Last Name (Required)

Home Phone

Cell Phone (Required)(Required)

Relationship (Required)(Required)

Name(Required)

First Name (Required)

Name(Required)

Last Name (Required)

Home Phone

Cell Phone (Required)(Required)

Relationship (Required)(Required)

Availability

Best day of the week (check all that apply)(Required)

Monday

Tuesday

Wednesday

Best time of day (check all that apply)(Required)

10am – 11am

2pm – 3pm

Are you available to commit to attending 7 out 9 meetings while serving on this committee? (note: there will not be meetings for the months of June, July, and December)(Required)

Yes

Confidentiality Agreement

Click HERE to review the GRMC Confidentiality Agreement

By checking this box, I read, understand, and agree with the GRMC Confidentiality Agreement and understand it is a requirement for me to volunteer at Guadalupe Regional Medical Center.(Required)

By checking this box, I read, understand, and agree with the GRMC Confidentiality Agreement and understand it is a requirement for me to volunteer at Guadalupe Regional Medical Center. (Required)

Application Agreement

Click HERE to review the GRMC Application Agreement.

By checking this box, I read, understand, and agree with the GRMC Application Agreement.(Required)

By checking this box, I read, understand, and agree with the GRMC Application Agreement. (Required)

PLEASE NOTE: All information contained in this application is considered confidential and is intended for use by the Guadalupe Regional Medical Center’s Patient and Family Advisor Council Committee. The Committee will maintain appropriate and confidential handling of personal information as stated in HIPAA guidelines and is presented in volunteer training. Qualified applicants will be selected to participate in a face-to-face interview. If selected, all Patient and Family Advisor Council applicants must complete volunteer service requirements as assigned by the Human Services department. These volunteer requirements include, but are not limited to the completion of the following: volunteer application, reference and criminal background check, volunteer orientation, HIPPA training, badge identification, and proof of the following immunizations: Influenza, Hep B, T-Spot, MMR, Tdap, and Varicella.

By signing my name below, I authorize without reservation, GRMC or it's representatives, to obtain information from all references (professional and personal), employers, public agencies, and educational agencies to otherwise verify the accuracy of all information provided by me and this application, resume, or job interview.(Required)

Patient and Family Advisory Council Application

General Information

Please respond to the questions below to help us get to know you better

Why do you want to join the Patient and Family Advisor Council?

Emergency Contact Information

References

Availability

Confidentiality Agreement

Application Agreement