Winslow Indian Health Care Center, Inc
Winslow Indian Health Care Center, Inc.
Compliment ( Complaint (
|Name: |Date: |
|Patient Relative Employee Visitor Other | |
|Address: |Phone: |
| | |
|City/State/Zip Code: |Chart # and or D.O.B.: |
| | |
|Person involved (if different than person completing Compliment /Complaint form): |
|Name/D.O.B./Chart #: |
|How Compliment/Complaint was presented: |
|Personal Visit Letter/Memo Telephone Call |
Check appropriate box below: Department and/or Name
Attitude (i.e., disrespectful, rude, etc) (courteous, helpful)
Waiting Time
Access to Services (i.e., appointments, clinics, etc.)
Privacy/Confidentiality
Services provided
Other (specify)
COMMENTS (Attach separate sheet if necessary):
|__________________________________________________________________________________________________________________________________________________________________|
|__________________________________________________________________________________________________________________________________________________________________|
|__________________________________________________________________________________________________________________________________________________________________|
|__________________________________________________________________________________________________________________________________________________________________|
|__________________________________________________________________________________________________________________________________________________________________|
|______________________________________________________________________________________________________________________________________________________ |
|Quality Management Department Use Only |
|Compliment ( Complaint ( |
|Tracking #: Date Received: |
|Department Head forwarded to for response: Date Forwarded: |
|Date Response Due: Date Response Received: Date letter sent to Patient: |
|Type of Follow-up: Meeting Letter Phone call |
|Comments: |
|Department Use Only |
|Name of Person taking Compliment/Complaint: |
|Telephone/Extension of Person taking Compliment/Complaint: ext. |
|Date Compliment/Complaint Received: Date Forwarded to Patient Advocate: |
|Department involved in Compliment/Complaint: |
04/25/2014
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