Compliments, Complaints and Feedback
1.
Please write your name OR write anonymous
*
2.
Choose one. Is this a:
(Required.)
Compliment
Complaint
Feedback/Other
3.
What was the event or situation?
4.
What was good or bad about this?
5.
What would you like to see done differently next time?
6.
from 1 (not at all) to 5 (absolutely)- describe how these statements apply to you:
1
2
3
4
5
I felt that I had choice and control
1
2
3
4
5
I felt that I was being heard
1
2
3
4
5
I felt that I was respected and valued
1
2
3
4
5
I felt positive about my experience
1
2
3
4
5
I felt that the support I received was appropriate for me
1
2
3
4
5
I felt that the support I received was tailored to my needs
1
2
3
4
5
Other (please specify)
7.
feel free to include any other comments here
8.
If you would like your complaint to be followed up- please provide a phone number or email to be contacted on.