Client Feedback Form

Client Feedback Form

Department of Health | Ho-Chunk Nation
Did you receive exceptional care? Do you have other questions, comments, or feedback for improvement? Let us know! Please write-in or check-mark (✔) the response which best reflects your answer and return this form to Quality Improvement Division.
Date of service (that feedback is related to)

MonthDayYear
Date
1.At which site is your feedback related to?

Black River FallsBarabooLa CrosseTomahWittenbergNekoosaMadison
2.What kind of feedback? (Check all that apply)

QuestionCommentFeedback for improvement (including complaints)
3.Which area of service did you use? (Check all that apply)

PharmacyOpticalDentalLab/radiologyClinic/medicalClinic RegistrationBenefits/billingBehavioral HealthEnvironmental HealthCommunity HealthNot listed (please write in):
Not listed (please write in)
4.Reason for feedback? (Check all that apply)

Scheduling/registrationClinic conditions cleanliness, temperature, etcCustomer serviceSafetyNot listed (please write in):
Not listed (please write in)
5.Please share a little more detail about your experience
Wa’iniginapsana! Thank you! We value your time and your feedback.
Complaint Section
If you have a concern about your experience or the services you received through the Ho-Chunk Nation Health Care facilities, please complete this section. All complaints are given serious attention and are kept confidential.
6.How could this situation have been prevented? (Check all that apply)

OrganizationPreparednessAttention to detailSympathy/compassionProfessionalism/respectFacility design/environment
Organization

CommunicationTrainingKnowledge of my cultureNot listed (please write in):
Not listed (please write in)
7.How can this situation be resolved? (Check all that apply)

Training/knowledgeCounselingUpdating policies or proceduresNot listed (please write in):
Not listed (please write in)
8.Is there anything else you would like to share with us about your experience?
Client Contact Information
Name
Address
Phone number
Email
example@example.com
I understand I may revoke this complaint in writing at any time, except to the extent that the action has been taken against this complaint.

Clear
Client Signature

MonthDayYear
Date
Should be Empty:

Client Feedback Form

Complaint Section

Client Contact Information