This volunteer application is for VIRTUAL ONLY Patient & Family Advisory Council members (PFAC).

If you are interested in becoming an ON-SITE Patient & Family Advisory Council member, please return to the website and complete the specific ON-SITE volunteer application.


Contact Information


Commitment & Assignment Preference

Patient & Family Advisory Council members must:
* Volunteer at least 2 hours per month (Volunteer opportunities may take place on any day of the week, weekdays, evenings, or weekends)
* Must commit to minimum terms as defined by local PFACs (typically 1-2 years minimum)
* Must have experience with health care as a patient, family member, or caregiver


Experience/Service Organizations

Please list any personal, professional or volunteer experience that you would like us to consider in your volunteer application. (List start and end dates along with position information. You may cut and paste information into this field.)


Interest

Why are you considering joining a PFAC and becoming an advising council member? (You may cut and paste information into this field.)


Value

What specifically about your experience would add value to our team of advisors? (You may cut and paste information into this field.)


Diversity

Our patient and family advisors reflect the diversity of the patients and families we serve. Please share anything about yourself that you think would add to the diversity of our team of advisors. (You may cut and paste information into this field.)


Additional Information


Emergency Contact

In case of an emergency, please list who we should contact.


References

Please provide us with 3 references in order to be considered for the Duke Health volunteer program. Choose references who have access to a computer and have the time to complete the reference within the one week timeframe. Family members cannot serve as references. Please inform your references that they will receive an email invitation to complete your reference.


How did you hear about our volunteer program?


Volunteer Services Agreement (Virtual Only)

As a VIRTUAL ONLY volunteer, I agree to attend Patient and Family Advisory Council (PFAC) meetings through a PFAC provided virtual platform only. I understand that as a VIRTUAL ONLY volunteer, I will not be authorized to enter any Duke Health entity as a part of my PFAC volunteer commitment and I will not be issued a Duke ID badge or parking privileges.

However, if my situation should change and I am authorized by the PFAC Coordinator to join us as an ONSITE volunteer, I will apply to Duke University Hospital Volunteer Services for the additional clearances needed. I understand that I am not to attend any ON-SITE meetings until I have been cleared and notified through the PFAC Coordinator and Volunteer Services and have been issued a current PFAC volunteer ID badge.

In connection with my activities as a volunteer I agree to hold confidential all information to which I may have access. This includes, but is not limited to, information on current, former, or prospective patients, employees, students, and scholars. Disclosure of such information to unauthorized persons is prohibited and may result in my dismissal from the volunteer program and may have additional legal consequences.

I am aware that Duke University Health System does not provide insurance coverage for volunteers if personally injured or if damage occurs to personal property while acting as a volunteer. I further understand that I am not entitled to worker’s compensation benefits, health insurance benefits, or any other benefit available to employees of Duke University Health System. I agree that I will not hold Duke University Health System or its officers or agents thereof liable for any injury sustained to person or property while acting in a volunteer capacity.

The information provided in this application for volunteering is true, correct and complete. If accepted as a volunteer, any misstatement or omission of fact on this application may result in my ineligibility for volunteering, or if accepted as a volunteer may result in my dismissal. I hereby authorize Duke University Health System to determine my suitability and justification for my role as a volunteer, to contact any or all of my references.

I authorize schools, employers and references named in this application to provide Duke University Health System with any relevant information that may be required to arrive at a decision regarding being accepted as a volunteer. In connections therewith and in consideration of the undertaking of Duke University Health System to review this application for volunteering and to consider me for a volunteer position, I hereby release and acquit Duke University Health System from any liability whatsoever for any damage which I may suffer or sustain by reason of its use of any such information.

I understand that should I be offered a VIRTUAL ONLY volunteer position, Duke University Health System conducts background checks when considering applicants for positions and that I will be requested to complete a background check form which requires date of birth and social security number to facilitate the background check. I understand that PFAC members must volunteer at least 2 hours per month and commit to minimum terms as defined by local PFACs (typically 1-2 years minimum).

I have completed the above information to the best of my ability and understand that any falsification of the information provided above may disqualify me to become a volunteer.