Patient and Family Advisory Council Registration

To help us get to know you better, please complete the following questions.

1. Are you a … *
PatientA family member of a patient

2. What language(s) do you speak? *
ArabicEnglishOther

3. Do you or your family member have any chronic health conditions? *
NoYes

4. When was your or your family member’s care experience at this hospital? (Check all that apply) *
20232022202120202019201820172016

5. Which unit(s) provided care for you or your family member? (Check all that apply) *

Pediatric and Adolescent Medicine Services
General Pediatric MedicineOncology/HematologyHematology-Oncology Outpatient Center (HOOC)Eating DisordersOutpatient Pediatric Infusion Center (OPIC)RheumatologyNephrologyDialysisPulmonologyPulmonary Function Testing LabSleep LabGastroenterology / Hepatology / NutritionEndocrinology & DiabetesAllergy & ImmunologyNeurologyNeurodiagnostics LabRehabilitation MedicineEmergency MedicineUrgent CarePoison CenterSidra Child Advocacy ProgramHeart Center and Cardiac ICUNeonatology / Neonatal Intensive Care Unit (NICU)High-Risk Infant Follow Up (HRIF)Pediatric Intensive Care Unit (PICU)DermatologyInfectious DiseasesDevelopmental PediatricsAdolescent MedicineMedical GeneticsHomecare & Case ManagementTrauma

Surgery Services
General SurgeryThoracic SurgeryNeurosurgeryOrthopedicsPlastics & CraniofacialEar, Nose & Throat (ENT)OphthalmologyDentistryTraumaUrologyCardiac SurgeryTransplant SurgeryPerioperative Services
Women’s Services
ObstetricsGynecologyMaternal-Fetal Medicine (MFM) / Obstetric DiagnosticsGeneral Internal MedicinePulmonary / Pulmonary Function TestingSleep LabCardiologyEndocrinologyReproductive Medicine / In Vitro Fertilization (IVF)

Clinical Services
Allied HealthRespiratory TherapyChild LifeSocial WorkPhysical TherapyOccupational Therapy and CastingClinical Nutrition and DieteticsSpeech And Language PathologyAnesthesiaPediatric AnesthesiaAdult AnesthesiaChronic Pain ServiceLaboratory & PathologyPharmacyMain Outpatient PharmacyCentral Inpatient PharmacyEmergency Department PharmacyInpatient Satellite PharmaciesOutpatient Satellite PharmaciesPsychiatryChild & Adolescent Mental Health ServiceWomen’s Mental Health ServicesRadiologyVaccination Services

Health Promotion Programs
Child Safety and Injury Prevention ProgramAntenatal EducationDiabetes Education For Children and ParentsHealth Awareness Campaigns

6. We recognize that our patient and family advisors have busy lives. How much time are you able to commit to being a patient and family advisor? (Check one) *
1 hour every other month1-2 hours every other month2-3 hours every other month

What times would work best for you? (Select all that apply) *
MorningAfternoonEveningOther

7. Are you available to serve as an advisor for at least 1 to 2 years? (You can still be an advisor if you answer “No”) *
YesNo

8. Would you be available to participate in a meeting for 90 to 120 minutes every other month? (You can still be an advisor if you answer “No”) *
YesNo

If yes, what times would work best for you? (Select all that apply)
MorningAfternoonEveningOther

9. How do you want to help? I want to: (Check all of your interest areas) *
Serve as a member of the patient and family advisory council. Potential advisory council members should be ready to commit to serving on the council for at least 1 to 2 years. The advisory council meets once a month for 1 ½ to 2 hours.Help develop or review informational materials for patients and family members.Help improve patient safety and the prevention of medical errors.Help improve the patient and family’s role in care decision-making.Help improve the hospital facilities (for example, patient care areas, or family resource rooms).Help educate or train hospital staff and clinicians.eview procedures and provide input to improve the hospital admission process.Provide input as we implement bedside shift reports, where nurses who are going off duty share information with nurses coming on duty at the patient’s bedside.Review procedures and provide input to improve transitions in care (for example, between hospital units or discharge from hospital to home).Other

10. Have you received any of the following vaccines? (Check all that is applicable) *
Tetanus, Diptheria and Pertussis: TdapVaricellaHepatitis BMumps, Measles, and RubellaTuberculosis (TB)NoneOther

11. If you have not been vaccinated with the above, would you be willing to take the required vaccinations? *
YesNo

Please tell us more about yourself.

5. Have you or a family member experienced health care services outside of Qatar? *
NoYes

6. Have you ever been convicted by the courts or cautioned, reprimanded, or given a final warning by the police? *
NoYes

7. Is there anything in your personal experience you would like to declare that might conflict with your participation in the PFAC? *
NoYes