Patient and Family Advisory Council Interest Form

JavaScript isn't enabled in your browser, so this file can't be opened. Enable and reload.

Mahalo for your interest in joining REHAB’s Patient and Family Advisory Council. Please submit the form below and a member of REHAB’s staff will reach out to you shortly. For additional questions, contact the Director of Quality at 808.566.3541.

Email *

First Name *

Last Name *

Phone *

Are you fluent in English? *

Yes

Which (if any) REHAB services have you received?
*

Inpatient

REHAB at Nuuanu

REHAB at Aiea

REHAB at Hilo

Physician’s Clinic

None

Required

What was the date of your most recent care experience (if any) at REHAB?

For what length of time would you be able to serve as an advisor?

1 Year

2 Years

Are you able to take on additional hours in between quarterly meetings? Please indicate the additional time (if any) you are able to commit to being an advisor.

1 to 2 hours per month

3 to 4 hours per month

5 hours or more per month

No additional time

Why would you like to be an advisor on REHAB’s Patient and Family Advisory Council?

Are there any particular topics (ex. programs, procedures, family experience, etc.) that interest you?

Do you have previous experience as a volunteer, advisor, or board member for other organizations? If yes, please explain.

Send me a copy of my responses.

Submit

Clear form

Never submit passwords through Google Forms.

reCAPTCHA

Privacy Terms

This form was created inside of Rehabilitation Hospital of the Pacific. Report Abuse

Forms