Patient Partner Advisory Council This field is hidden when viewing the formDate Submitted MM slash DD slash YYYY Full Name(Required) First Last Address(Required) Street Address City StateAlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Primary Phone Number(Required)Alternative Phone NumberBest time to call(Required)DayMondayTuesdayWednesdayThursdayFridayDayTimeTime Email Address(Required) I prefer contacted via :(Required) Phone Email The following questions are designed to help us get to know our potential Patient/Family partners better, and to help us build a diverse group of volunteers. All answers will be kept confidential.Gender(Required) Male Female Transgender Genderfluid Non-binary Prefer Not to Answer Are you?(Required) Hispanic/Latino Not Hispanic/Latino Race/Ethnicity :(Required) White Black or African American American Indian or Alaska Native Asian Native Hawaiian or Other Pacific Islander Two or More Races Prefer Not to Answer Other Primary language spoken :(Required)EnglishEspañolSomaliFrenchGermanItalianRussianMandarinCantoneseJapaneseKoreanVietnameseHindiArabicTurkishOtherWhat is the highest school level completed?(Required) High School/GED Some College College Graduate Master's Degree PHD Age :(Required) 18-24 25-34 35-44 45-54 55-64 65 or Above Do you or your spouse/partner work for the Mankato Clinic or any of its affiliates?(Required) Yes No Do any of your family members work for the Mankato Clinic or any of its affiliates?(Required) Yes No If yes, please describe your relationship :Do you have children under age 18?(Required) Yes No If yes, What is/are their age(s): Add RemoveAre you a caregiver for any other family member or friend? Yes No (If yes, please explain your situation) ------->UntitledWhat clinic do you (and/or your family) receive most of your health care :Who is your Primary Care Provider?(Required)What health care issues interest you most? (Check all that apply) : Prevention Chronic Diseases Elder Care Affordability Behavioral Health Family Medicine Pediatrics Oncology Patient Experience Select AllPlease describe your availability (specify days of the week and hours of the day) :Do you have areas of special interest or expertise to offer? If yes, please explain.What do you hope to contribute to the Parents/Family Advisory Council?Is there anything else you would like us to know about you or your healthcare experience?I understand that completion of this Form does not bind the candidate or the program coordinators in any way. The Patient /Family Advisory Council coordinators will choose participants that best meet the needs of the program and assign them accordingly. Before participating in the Council you will be required to complete a formal training program.Consent(Required) I agree to the privacy policy.(Required)
