Tribal Public Health Client Feedback Form

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1. Please provide the date that you received services that you would like to provide feedback about.

Date / Time

Date

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2. Type of Feedback

Concern/Complaint

Compliment

Suggestion

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3. Are you a:

Person who has received tribal public health services (Ex. WECARE, diabetes prevention programming, health fairs)

A community partner organization

Community member

Other (please specify)

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4. Please provide details with your feedback.

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5. Would you like us to contact you related to your feedback? If yes, please provide the best number or email to contact you.