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Complaints/Feedback Form
Please answer each of the following questions if you have a complaint or feedback about ELMO Health.
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1
What is your name?
*
This field is required.
If you are completing this on behalf of someone else, what is the name of the person submitting the complaint/feedback? If you wish to remain anonymous, please type anonymous. Please note however that this will make it more difficult for ELMO Health to rectify any issues.
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2
Who is the person, or what is the service, about whom you are complaining or providing feedback about?
*
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3
Does the person know you are making this complaint/providing feedback?
*
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YES
NO
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4
What is your complaint/feedback about?
*
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Would you please provide some details to help us understand your concerns? You should include what happened, where it happened, the time it happened, and who was involved?
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5
Are there any documents that support your complaint/feedback?
*
This field is required.
These may be asked for during the investigation.
YES
NO
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6
What outcomes are you seeking because of the complaint/feedback?
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