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Home / Patients & Visitors / Patient and Family Advisory Council

Patient and Family Advisory Council

DO YOU HAVE IDEAS TO HELP MAKE OUR HOSPITAL BETTER?

We want to hear from you! We are looking for patients and family members to join our team and help improve care, safety, and the patient experience.

- Share your story and your ideas
- Help improve how we communicate with patients
- Work directly with hospital staff and leaders
- Patients or family members who received care at Waterbury Hospital
- People who want to help make healthcare better for others
- Anyone willing to share honest feedback and new ideas

PFAC Application Form

Do you have ideas to help make our hospital better? We want to hear from you! We are looking for patients and family members to join our team and help improve care, safety, and the patient experience.

You must be logged in to submit the form.

The Council requires a 4-month commitment. Are you able to commit? Yes No Maybe

What services have you used? Emergency Room Blood Draw Stations I've been admitted to a floor/unit Outpatient Doctor's Office

Your Full Name

Your Date of Birth

Why are you interested in joining the Council?

What if your gender identity

What are your preferred pronouns?

What is your sexual orientation?

What is your ethnic or cultural background?

What languages can you speak?

Do you identify with a religion? (If yes, please indicate the religion you identify most closely to. If not simply enter NO.)

Are you hearing or visually impaired? Hearing Visual Both Neither

Do you require an interpreter? If so, enter What language interpreter/translator

Home Address

Your City

Your Zip Code

Your Cell Phone Number

Your Email Address

Have Questions?

Phone: 203-573- 6285
Email: Mesha.Esson@wtbyhosp.org

Contact

Hospital Address
64 Robbins St.
Waterbury, Connecticut 06708

Phone Directory
203.573.6000

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