[{"data":1,"prerenderedAt":-1},["ShallowReactive",2],{"doc-seo-170982-105":3,"detail-sidebar-cat-1-en-105":73,"doc-detail-170982-en":119},{"code":4,"msg":5,"data":6},0,"ok",{"site_id":7,"language":8,"slug":9,"title":10,"keywords":11,"description":12,"schema_data":13,"social_meta":66,"head_meta":68,"extra_data":70,"updated_unix":72},105,"en","patient-family-advisor-application-application-template","Patient & Family Advisor Application - Application Template","","Patient & Family Advisor Application template for organizations seeking partners to support patient- and family-centered care. Collects candidate contact details, preferred communication method, and eligibility context including patient status, family relationship, chronic conditions, and preventive or occasional care involvement. Includes sections for skills and interests, preferred participation formats such as phone interviews, focus groups, committee work, story sharing, and advisory council membership. Captures availability by day and time, and directs applicants to contact the liaison and submit the completed form via a return envelope.",{"@graph":14,"@context":65},[15,34,56],{"@type":16,"itemListElement":17},"BreadcrumbList",[18,23,27,31],{"item":19,"name":20,"@type":21,"position":22},"https://docshare.wps.com","Home","ListItem",1,{"item":24,"name":25,"@type":21,"position":26},"https://docshare.wps.com/template/","Template",2,{"item":28,"name":29,"@type":21,"position":30},"https://docshare.wps.com/template/forms/","Forms",3,{"item":32,"name":10,"@type":21,"position":33},"https://docshare.wps.com/template/patient-family-advisor-application-application-template/170982/",4,{"url":32,"name":10,"@type":35,"image":36,"author":41,"headline":10,"publisher":44,"fileFormat":47,"inLanguage":8,"description":12,"dateModified":48,"datePublished":49,"encodingFormat":47,"isAccessibleForFree":50,"interactionStatistic":51},"DigitalDocument",{"url":37,"@type":38,"width":39,"height":40},"https://docshare.wps.com/thumbnails/patient-family-advisor-application-application-template/170982.png","ImageObject",442,249,{"name":42,"@type":43},"\tJames","Person",{"url":19,"name":45,"@type":46},"DocShare","Organization","application/vnd.openxmlformats-officedocument.wordprocessingml.document","2026-10-23","2026-09-01",true,{"@type":52,"interactionType":53,"userInteractionCount":55},"InteractionCounter",{"@type":54},"ViewAction",7,{"@type":57,"mainEntity":58},"FAQPage",[59],{"name":60,"@type":61,"acceptedAnswer":62},"Where should completed applications be submitted and who can be contacted for questions?","Question",{"text":63,"@type":64},"The form instructs applicants to return the completed application using the enclosed return envelope and to contact the liaison by the listed email and phone number if questions arise.","Answer","https://schema.org",{"og:url":32,"og:type":67,"og:title":10,"og:site_name":45,"og:description":12},"article",{"robots":69,"canonical":32},"index,follow",{"doc_id":71,"site_id":7},170982,1790178114,{"code":4,"msg":74,"data":75},"success",[76,81,86,91,96,101,105,110,115],{"id":77,"doc_module":22,"doc_module_name":25,"category_name":78,"show_sort_weight":79,"slug":80},11,"Presentations",90,"presentations",{"id":82,"doc_module":22,"doc_module_name":25,"category_name":83,"show_sort_weight":84,"slug":85},12,"Resumes",80,"resumes",{"id":87,"doc_module":22,"doc_module_name":25,"category_name":88,"show_sort_weight":89,"slug":90},14,"Invoices",70,"invoices",{"id":92,"doc_module":22,"doc_module_name":25,"category_name":93,"show_sort_weight":94,"slug":95},15,"Posters",60,"posters",{"id":97,"doc_module":22,"doc_module_name":25,"category_name":98,"show_sort_weight":99,"slug":100},16,"Social Media",50,"social-media",{"id":102,"doc_module":22,"doc_module_name":25,"category_name":29,"show_sort_weight":103,"slug":104},17,40,"forms",{"id":106,"doc_module":22,"doc_module_name":25,"category_name":107,"show_sort_weight":108,"slug":109},18,"Letters",30,"letters",{"id":111,"doc_module":22,"doc_module_name":25,"category_name":112,"show_sort_weight":113,"slug":114},21,"Paper Templates",5,"papers-templates",{"id":116,"doc_module":22,"doc_module_name":25,"category_name":117,"show_sort_weight":4,"slug":118},158,"General","general-158",{"code":4,"msg":74,"data":120},{"doc_id":71,"user_id":121,"nickname":42,"user_avatar":122,"doc_module":22,"category_id":102,"category_name":29,"doc_title":10,"doc_description":12,"doc_content":123,"file_id":124,"file_url":125,"file_type":126,"file_size":127,"view_count":55,"is_deleted":4,"is_public":22,"is_downloadable":22,"audit_status":22,"page_count":26,"language":128,"language_code":8,"site_id":7,"html_lang":8,"table_of_contents":129,"faqs":130,"seo_title":131,"seo_description":12,"update_tm":132,"read_time":22},2336474466412,"https://ap-avatar.wpscdn.com/davatar_155a257f0dc6eb9ab79c44ca47cae57d","YOUR ORGANIZATION NAME\nPatient & Family Advisor Application\nWould you be a partner with us to deliver patient- and family-centered care every time in every encounter?  To reach this goal, we need your ideas, feedback and participation as together we improve the experience of care for our patients and families.  We are seeking individuals for a variety of opportunities – both short term and ongoing.\nDate:\nName:\nLast\t\t        \t\t\t\t First\t\t       \t\t\t MI\nAddress: \t\t\t\t\t\tCity: \t\t\t      State: \t      Zip:\nHome Phone:\t\t\t\t Work Phone:\t\t\t              Cell Phone:\nEmail\u001f\u001f\u001f\u001f:\nWhat is the best way to contact you?   (circle one)    Home    Work    Cell    Email\nPlease check all that apply below:\n□ I am a patient at a name of hospital/clinic or facility\n→If yes, from which location(s) do you receive services?\n□ I am the family member of a patient from :\n□ I am a patient with a chronic health condition (e.g., diabetes, heart failure, asthma, depression, arthritis)\n□ I am involved in the care of someone who has a chronic health condition\n□ I am a patient/family member receiving preventative and/or occasional illness care\nSKILLS & INTERESTS   If you wish to provide more information, please use the space below to describe any special training, interests, hobbies or experiences you feel could be valuable to your work as a Patient/Family Advisor with us.\nPlease indicate the ways in which you would like to participate as a Patient/Family Advisor:\n___ Phone Interview:  Share your opinion and respond to survey questions over the telephone.\n___ Focus Group:  Provide feedback in a group format with other patients/family members.\n___ Participate on Committees:  Bring the patient/family voice/experience to committee meetings.\n___ Story Sharing:  Share your health care experiences with care providers and other patients.\n___ Be a partner in making improvements to specific health care services.\n___ Be a member of a Patient Family Advisory Council (monthly evening meetings)\n___I don’t know yet, I need more information.\nPlease put an ‘X’ in the Day(s) and Time(s) you are available to meet for an interview and/or informational session:\nYour responses are important in planning your involvement with us.  If you have questions concerning the program or this application, please call NAME OF LIAISON, E-MAIL AND PHONE NUMBER.\nPlease return your completed application using the return envelope enclosed.\nAdapted from Participating Clinics in the Quality Corporation’s Patient and Family as Leaders Program in Oregon\nIncluded in Minniti, M. M., & Abraham, M. R. (2013). Essential Allies—Patient, Resident, and Family Advisors: A Guide for Staff Liaisons. Bethesda, MD: IPFCC.","cbCain9C0rF0C2lP","https://ap.wps.com/l/cbCain9C0rF0C2lP","docx",46822,"English","# Patient & Family Advisor Application\n## Applicant Information\n## Skills, Interests, and Participation Preferences\n## Availability and Submission Instructions","[{\"question\":\"Where should completed applications be submitted and who can be contacted for questions?\",\"answer\":\"The form instructs applicants to return the completed application using the enclosed return envelope and to contact the liaison by the listed email and phone number if questions arise.\"}]","Patient & Family Advisor Application - Application Template | DOCX",1788278439]