Full Name *
Nationality *
Religion *
Date of birth *
Address (City, Zone, Street no., House no.) *
Mobile no. *
Email address *
Educational level *
Occupation (Job) *
Preferred contact (the best way to contact you for any future inquiries) * Phone callEmailSMS
1. Are you a … * PatientA family member of a patient
2. What language(s) do you speak? * ArabicEnglishOther [conditional group-other-language] Please specify: [/conditional]
3. Do you or your family member have any chronic health conditions? * NoYes
4. When was your or your family member’s care experience at this hospital? (Check all that apply) * [selct_multiselct* Experience multiple placeholder:Select-Year class:form-select "2026" "2025" "2024" "2023" "2022" "2021" "2020" "2019" "2018" "2017" "2016"]
5. Which unit(s) provided care for you or your family member? (Check all that apply) *
Pediatric and Adolescent Medicine Services [selct_multiselct* Pediatric-Adolescent multiple placeholder:Select-Services size:100% class:form-select "General Pediatric Medicine" "Oncology/Hematology" "Hematology-Oncology Outpatient Center (HOOC)" "Eating Disorders" "Outpatient Pediatric Infusion Center (OPIC)" "Rheumatology" "Nephrology" "Dialysis" "Pulmonology" "Pulmonary Function Testing Lab" "Sleep Lab" "Gastroenterology / Hepatology / Nutrition" "Endocrinology & Diabetes" "Allergy & Immunology" "Neurology" "Neurodiagnostics Lab" "Rehabilitation Medicine" "Emergency Medicine" "Urgent Care" "Poison Center" "Sidra Child Advocacy Program" "Heart Center and Cardiac ICU" "Neonatology / Neonatal Intensive Care Unit (NICU)" "High-Risk Infant Follow Up (HRIF)" "Pediatric Intensive Care Unit (PICU)" "Dermatology" "Infectious Diseases" "Developmental Pediatrics" "Adolescent Medicine" "Medical Genetics" "Homecare & Case Management" "Trauma"]
Surgery Services [selct_multiselct* Surgery-Services multiple placeholder:Select-Services size:100% class:form-select "General Surgery" "Thoracic Surgery" "Neurosurgery" "Orthopedics" "Plastics & Craniofacial" "Ear, Nose & Throat (ENT)" "Ophthalmology" "Dentistry" "Trauma" "Urology" "Cardiac Surgery" "Transplant Surgery" "Perioperative Services"]
Women’s Services [selct_multiselct* Women-Services multiple placeholder:Select-Services size:100% class:form-select "Obstetrics" "Gynecology" "Maternal-Fetal Medicine (MFM) / Obstetric Diagnostics" "General Internal Medicine" "Pulmonary / Pulmonary Function Testing" "Sleep Lab" "Cardiology" "Endocrinology" "Reproductive Medicine / In Vitro Fertilization (IVF)"]
Clinical Services [selct_multiselct* Clinical-Services multiple placeholder:Select-Services size:100% class:form-select "Allied Health" "Respiratory Therapy" "Child Life" "Social Work" "Physical Therapy" "Occupational Therapy and Casting" "Clinical Nutrition and Dietetics" "Speech And Language Pathology" "Anesthesia" "Pediatric Anesthesia" "Adult Anesthesia" "Chronic Pain Service" "Laboratory & Pathology" "Pharmacy" "Main Outpatient Pharmacy" "Central Inpatient Pharmacy" "Emergency Department Pharmacy" "Inpatient Satellite Pharmacies" "Outpatient Satellite Pharmacies" "Psychiatry" "Child & Adolescent Mental Health Service" "Women’s Mental Health Services" "Radiology" "Vaccination Services"]
Health Promotion Programs [selct_multiselct* Promotion-Programs multiple placeholder:Select-Services size:100% class:form-select "Child Safety and Injury Prevention Program" "Antenatal Education" "Diabetes Education For Children and Parents" "Health Awareness Campaigns"]
6. We recognize that our patient and family advisors have busy lives. How much time are you able to commit to being a patient and family advisor? (Check one) * 1 hour every other month1-2 hours every other month2-3 hours every other month
What times would work best for you? (Select all that apply) * MorningAfternoonEveningOther [conditional group-other-time] Please specify: [/conditional]
7. Are you available to serve as an advisor for at least 1 to 2 years? (You can still be an advisor if you answer “No”) * YesNo
8. Would you be available to participate in a meeting for 90 to 120 minutes every other month? (You can still be an advisor if you answer “No”) * YesNo
If yes, what times would work best for you? (Select all that apply) MorningAfternoonEveningOther [conditional group-other-available] Please specify: [/conditional]
9. How do you want to help? I want to: (Check all of your interest areas) * Serve as a member of the patient and family advisory council. Potential advisory council members should be ready to commit to serving on the council for at least 1 to 2 years. The advisory council meets once a month for 1 ½ to 2 hours.Help develop or review informational materials for patients and family members.Help improve patient safety and the prevention of medical errors.Help improve the patient and family’s role in care decision-making.Help improve the hospital facilities (for example, patient care areas, or family resource rooms).Help educate or train hospital staff and clinicians.eview procedures and provide input to improve the hospital admission process.Provide input as we implement bedside shift reports, where nurses who are going off duty share information with nurses coming on duty at the patient’s bedside.Review procedures and provide input to improve transitions in care (for example, between hospital units or discharge from hospital to home).Other [conditional group-other-interest] Please specify: [/conditional]
10. Have you received any of the following vaccines? (Check all that is applicable) * Tetanus, Diptheria and Pertussis: TdapVaricellaHepatitis BMumps, Measles, and RubellaTuberculosis (TB)NoneOther [conditional group-other-vaccines] Please specify: [/conditional]
11. If you have not been vaccinated with the above, would you be willing to take the required vaccinations? * YesNo
1. Why would you like to become a patient and family advisor? *
2. Please briefly describe any experience you may have as an advisor, as a volunteer, or as a public speaker. *
3. Please describe any specific things that doctors or hospital staff did or said while you or your family member were in the hospital that: • were helpful to you or your family • could have done differently to be more helpful while you or your family member *
4. Please share anything about yourself that you think would add to the diversity of our team of advisors. (For example Background, education, skills, experience, special interest, etc.) *
5. Have you or a family member experienced health care services outside of Qatar? * NoYes
6. Have you ever been convicted by the courts or cautioned, reprimanded, or given a final warning by the police? * NoYes
7. Is there anything in your personal experience you would like to declare that might conflict with your participation in the PFAC? * NoYes
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