What language(s) do you speak? *
Why do you want to become a patient and family advisor?
Do you volunteer in your community? If so, for which organizations?
Do you feel comfortable working in groups, speaking up, and providing input?
In your OB experience what did we do well?
What could we have done better?
What would you like the hospital to learn from your experience in OB?
Please provide details, if possible, about the chosen areas above. If you feel there are other areas not listed, please list.
Are there certain topics or areas in which you have a special interest?*