Health Care Advisor Expression of Interest (fillable PDF download)
Name (required)
Phone Numbers
Home
Work
Cell
Email (required)
Preferred Contact Method Home PhoneWork PhoneCell PhoneEmail
When are you available? DaytimeEveningWeekend
How did you hear about this opportunity? NewspaperRadioWord of mouthHealth Care ProviderBrochureWebsiteOther
The Northern Health Region is interested in ensuring it is representative and inclusive of Manitoba’s diverse population. We are inviting you to list the group(s) you identify with (e.g. First Nation, Metis, Newcomer, Persons living with a disability, Young Adult, Transgender, etc.).
Will you require any supports in order to participate (e.g. translator, note-taker, amplification, etc.)?
Have you received care, or supported a loved one in receiving care over the last 5 years? YesNo Some programs may need more specific information about type of diagnosis or type of care.
Which of the following opportunities would interest you? Ongoing and regular commitment to an advisory bodyParticipating in periodic focus groupsParticipating on committees with health professionals to help improve servicesParticipating from home (e.g. answering surveys, reviewing educational documents)Participating in program and policy developmentSharing my personal health care story to help improve servicesOther:
What aspects of health care interest you the most (e.g. patient safety, health promotion, making the system better, etc.)?
Would you be interested in participating in any other type of initiatives? YesNoMaybe
If you live in rural Manitoba, would you be interested in participating virtually, such as via Telehealth? YesNo
Employment Status Employed Full-TimeEmployed Part-TimeUnemployedRetiredHomemaker/CaregiverStudent
What kind of work do/did you do?
Do you have any special skills or training (e.g. comfort with interpreting data, familiar with medical terminology, giving presentations, etc.)?
Tell us why you are interested in participating as a Health Care Advisor.
References
1. Name
Phone Number
2. Name
3. Name
I am willing to sign a confidentiality form
Questions? Call: (204) 687-9320
Toll-free: 1-888-340-6742
Send your completed form to:
Patient Experience Coordinator Box 340 Flin Flon General Hospital 3rd Avenue & Church Street Flin Flon, Manitoba R8A 1N2 Or via email to patientexperience@nrha.ca
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