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Patient and Family Advisory Council Application

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Thank you for your interest in joining the UT Southwestern Simmons Comprehensive Cancer Center's Patient and Family Advisory Council (PFAC). Patients, family members, and care partners who serve as advisors share their experiences on policies, programs, facility design and care delivery in many different settings. This partnership with patients and families helps ensure our Cancer Center is providing the highest level of comprehensive and compassionate care

Applications are reviewed upon receipt. Potential members are contacted for on-site interviews with staff and Council members.

Name

Address

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Telephone

Work Phone

Home Phone

Cell Phone

Email address

Preferred method of contact

Phone

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Please select your connection to Simmons Comprehensive Cancer Center.

Patient currently in treatment

Cancer survivor

Bereaved family member

Care partner of patient currently in treatment

Care partner of cancer survivor

Please provide years post-treatment

Relationship to patient:

Patient Diagnosis (type of cancer)

Patient age at diagnosis

Year of original diagnosis

Year treatment was completed (if applicable)

Please briefly describe your cancer experience as a patient, care partner, or family member.

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Why would you like to be a member of the Patient and Family Advisory Council?

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What does advocacy mean to you?

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Please add any other information that you would like for us to consider in the selection process, such as professional experience, volunteer work, advocacy efforts, or other considerations.

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If selected, on which committee would you be most interested serving?

Patient experience

Education

Research and Advocacy

Please indicate if you participated in any of the below supportive programs provided at Simmons.

EMBRACE Survivorship Symposium

Families Connected

Music Therapy

Oncology Nutrition

Oncology Rehabilitation

Oncology Social Work

One-on-One Support

Psycho-Oncology

Spiritual Support

Support Groups & Classes

Which location did treatment take place?

Dallas campus

Richardson campus

Moncrief

Red Bird

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