Patient, Family, and Community Council (PFAC) Application

This application is for any individual who has been a patient, or was a caregiver of a patient at UConn Health, John Dempsey Hospital.

Personal Information
Contact Information
Emergency Contact
Availability
Sunday
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Additional Information
Race
Have you or a member of your support network received care at any of the following UConn Health Services? Check all that apply.
This application is for patients and their networks who receive care at UConn Health. Please review our other applications to apply for another opportunity.
Agreement
  1. I am giving consent to having my application be visible to UConn Health Staff to determine eligibility and to having information enclosed in this application to be shared internally within UConn Health.
  2. I confirm that I have provided complete and accurate information in this application.   
  3. I authorize UConn Health to take my photograph in relation to my volunteer position.   
  4. For the safety of patients, their families, and hospital staff, the screening process for volunteer applicants over the age of 18 includes a comprehensive background check to be conducted with your signed authorization, following your interview.
  5. I am available for three years to serve as an advisor
  6. I will hold as absolutely confidential all information that I may obtain directly or indirectly concerning patients or personnel and not seek to obtain confidential information from a patient.  
  7. I understand that I may be dismissed from my duties if I fail to comply with hospital policies and procedures, willful wrongdoing or negligence and/or performing duties outside of my service guidelines, inappropriate behavior, or any other circumstances deemed contrary by the department of Volunteer Services to the best interests of the hospital.  
  8. I understand that I am expected to inform the Department of Volunteer Services of any significant change in my health status that would negatively impact on my ability to perform the tasks to which I am assigned.  
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