Community Engagement Advisory Network (CEAN) Patient & Public Involvement in Healthcare
Application Form

Please fill out the form below if you are interested in joining CEAN.  Once you have submitted this application a staff member from Vancouver Coastal Health Community Engagement will get in touch with you to set up a phone interview.

Please note that the information provided in this application and subsequent interview will be held in our database and kept confidential.  The information is used to understand the areas of interest and experiences of our CEAN members, to facilitate placements as advisors on projects or committees.  
Address
Please tell us which of the following describe you? (Please check all that apply)

Why are you interested in patient/public involvement with healthcare services?
Please tell us about your connections to (and/or work with) community groups and networks (e.g. faith groups; online networks; neighbourhood, student or professional associations, etc.)
What do you hope to gain from your experience with CEAN?
How did you hear about CEAN?
I am interested in the following areas of healthcare
I would like to be involved in the following way(s): (please check all options that interest you)
YesNo
I would be interested in acting as an advisor on the content and user-friendliness of patient/family information materials
I would be interested in joining a patient reference group or advisory committee
I would reply to questionnaires or surveys that were sent to me about health services
I would be interested in sharing my story/experiences to support staff education and quality improvement

What time would you normally be available for these activities? (Please check all that apply)
We are fostering the growth of a diverse network of advisors. Please tell us a little more about yourself:
Age Range:
 I identify as:
Ethnicity:
Thank you. Click 'finish' below to submit your application. A staff member from Vancouver Coastal Health Community Engagement will get in touch with you to set up a phone interview. If you don't hear from someone within 2 weeks, or if you have any questions or would like to speak to someone in person, please e-mail ce@vch.ca or call 604-714-3779.