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Name*

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Email*

Phone*

Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Year of Birth*

Gender*

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Other. Please specify below.
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Gender (Other)

Geographic Region*

Are you a member of any of the following groups? (Please check all that apply)*

Visible minority
Person with disabilities
Aboriginal (First Nations / Metis / Inuit)
Recent immigrant to Canada
LGBTQ
Other. Please specify below.
None of the above
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Are you a member of any of the following groups? (Other)

How did you hear about Patient Voices Network?*

Which social media?*

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From which organization?

Who?

Which?

What interests you about Patient Voices Network?*

What do you hope to gain from your involvement in the Network?*

What experience do you have (volunteer, paid work, professional and education) that you feel is relevant to being a volunteer with the Network?*

Are there specific areas of the health care system that you are most interested in getting involved in?*

What makes you feel appreciated? How would you like to be recognized for your work with the Network?*

Do you have any accessibility or dietary requirements we should be aware of?*

Have you ever worked for pay in a health care profession?*

Yes, currently working.
Yes, but not anymore.
No.

Is there anything else about yourself that you would like to share? Do you have any final questions?

Newsletter Sign-Up

Sign me up to also receive newsletters from the BC Patient Safety & Quality Council

You'll begin receiving (typically) bi-weekly newsletters that originate from our provider, Cyberimpact, and you'll be able to unsubscribe at any time. To contact us with questions, visit www.bcpsqc.ca/contact.

If you're having issues completing this questionnaire, please phone 604.668.8210 or send an email to info@bcpsqc.ca

The BC Patient Safety & Quality Council will collect personal information via Word Press under section 26 (c) of the Freedom of Information and Protection of Privacy Act for the purposes of operating the Patient Voices Network. Personal Information submitted by volunteers will be saved and stored on file by BCPSQC for 5-10 years upon submission. If you have any questions about the collection of your personal information please contact: Ben Ridout, Director of Patient and Public Engagement, 201-750 West Pender St., Vancouver, BC, at 604-668-8211.

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