Patient Family Advisory Council Application

Please tell us your experience at Kalispell Regional Healthcare.

Today's Date *

Have you ever been hospitalized at Kalispell Regional Medical Center or The HealthCenter for more than 24 hours?
Yes   No  

If your answer is YES, how long was your longest hospitalization?

Have you ever been a care-giver for a patient who was hospitalized at Kalispell Regional Medical Center or The HealthCenter for more than 24 hours?
Yes   No  

If your answer is YES, how long was the longest hospital stay of the person you were caring for?

How many times have you or a person you take care of been hospitalized at Kalispell in the last three years?

How would you describe that hospital experience?

What did the hospital do well during your stay or your loved one’s stay?

What could the hospital have done better during your stay or your loved one’s stay?

What would you like the hospital to learn from your stay or your loved one’s stay?

If you have more to say, please feel free to use this space.

Your name

Your address

Your email address

Your phone number

Your mobile number

Do you volunteer in your community? If so, for which organizations?

Do you feel comfortable working in groups, speaking up and providing input?

Is English the language you primarily use when communicating?
Yes   No  

If your answer is no, what is your primary language?

Are you able to attend meetings at Kalispell during weekday evenings?
Yes   No  

Are you willing to take the necessary immunizations to serve on the Patient Family Advisory Council?
Yes   No  

Are you willing to sign an agreement promising not to disclose confidential information given to you in your role as a member of the Patient Family Advisory Council?
Yes   No  

Are you willing to undergo a background check?
Yes   No