The ICSI Patient Advisory Council

ICSIPatient Advisory Council Application

First Name: Last Name:

Mailing Address:

City: State: Zip Code:

Phone: (include area code)Other Phone:(include area code)

Best time to call: Email address:

How did you hear about the ICSI Patient Advisory Council?

*The following questions should be answered on a volunteer basis only and are designed to help us recruit a variety of talent.

*Gender: Male: Female:

*Are you 18 years or older? Yes No

*Age range that best describes you: 18-2930-5050-65 66+

*What is the highest level of education you have completed?

High School/GED Some College College graduate Master’s degree Ph.D

*What languages do you speak or write fluently?

What health care issues interest you: (Check all that apply)

Prevention

Chronic Diseases

Quality

Care of the elderly

End of life care

Patient Safety and Education

Helping patients make better health choices

Affordability

Family Medicine

Children’s health needs

Healthy Communities

Other (please describe)

Do you have any areas of special interest or expertise to offer?

If so, how do you see it contributing to the Patient Advisory Council?

Why do you want to participate in the Patient Advisory Council? Includewhat you hope to contribute and the experience you hope to gain.

Electronic Signature: Date:

By signing my signature, I understand that this application does not bind ICSI or me in any way. ICSI reserves the right to select participants that best meet the needs of the Patient Advisory Council.

Submit your application one of the following ways:

• Email application to:
• Fax application to: (952)-814-7081, attention Rochelle Hayes
• Mail application to: Institute for Clinical Systems Improvement, 8009 34th Avenue South, Suite 1200, Bloomington, MN 55425, attention: Rochelle Hayes

Once your application is received, you will be contacted to schedule abrief interview. For additional questions contactJeyn Monkman at ICSI at (952) 883-7980 or at .