Patient / Caregiver Partnership Council Application

Today's Date:

Home Address:

E-mail:

I am the

Patient

Spouse

Caretaker

Parent

Other

Recent Work Experience:

Education:

Within the past two years, have you or a loved one received care at any of the following Carson Tahoe services? Please check all that apply.

Outpatient

Inpatient

Emergency Department

Other programs, services

If other, please list:

1. Why are you interested in becoming a Patient/Caregiver Council Member?

2. If you have volunteered or participated in any organization or committees, please share some examples:(These examples may be from work, community, church)

3. The attributes of a good Partnership Council member include being a good listener, having excellent communication skills, working collaboratively, and maintaining confidentiality. Do you believe you have these attributes and why?

4. Have you done public speaking or teaching? Please describe.

5. What special interests, experiences, talents would you offer the Partnership Council and/or how does your voice uniquely represent the community?

6. For those participating with in-person meetings beginning August 9, 2021, they will be held on the second Monday of the month, every other month, from 12:00 PM – 1:00PM. Can you meet during that time?

Yes

No

7. Council members frequently communicate through Zoom and email, using Word/Excel/PowerPoint. Are you able to use zoom, as well as receive documents via email in these formats?

Yes

No

8. Describe your experience, positive or negative, as a patient and/or loved one at Carson Tahoe Health.

9. How did you hear about the Council?

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Patient/Caregiver Partnership Council Application