Form YG6537 "Feedback Form" - Yukon, Canada

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CONTINUING CARE
FEEDBACK FORM
HOW ARE WE DOING?
To be completed by clients, family or other members of the public
My name is:
I am reporting a
I am reporting this on behalf of:
Complaint
(please check one):
A home care client
Myself
Compliment
Suggestion
A facility resident
Other (specify): ________________________
Provide some details about your feedback. Include the date and location of the incident. Please include the names of
any staff (if known and if applicable).
YG(6537EQ)F2 Rev.02/2019
Page 1 of 2
CONTINUING CARE
FEEDBACK FORM
HOW ARE WE DOING?
To be completed by clients, family or other members of the public
My name is:
I am reporting a
I am reporting this on behalf of:
Complaint
(please check one):
A home care client
Myself
Compliment
Suggestion
A facility resident
Other (specify): ________________________
Provide some details about your feedback. Include the date and location of the incident. Please include the names of
any staff (if known and if applicable).
YG(6537EQ)F2 Rev.02/2019
Page 1 of 2
Would you like to be contacted by a manager/supervisor?
Yes
No
If yes, tell us the best time and way of contacting you:
Time of day: ____________________________________________________________________________________
Phone: _________________________________________________________________________________________
Email: _________________________________________________________________________________________
Continuing Care values your perspective. Your feedback contributes to the value and quality of the services provided
by Continuing Care. If you have asked us to contact you, you can expect a response as follows:
For urgent issues, please speak directly to a supervisor or manager. You can expect to be contacted within 4 hours
of reporting an urgent issue. Continuing Care defines ‘urgent’ as an issue that, if not addressed immediately, puts
someone at risk of injury, death or loss.
For non-urgent issues, you will be contacted within 2 business days of this form being received by a
Continuing Care employee.
You can submit this form in-person to:
• Any Continuing Care employee, during their regular work day,
• Any Continuing Care building, including Home Care offices, long-term care homes or the Continuing Care
building at 109 Copper Rd, Whitehorse
You can fax this form to:
• 867-393-6953, Attn: Manager, Quality, Risk and Clinical Practice
You can email this form to:
• hss-cc-managers@gov.yk.ca
If this is an urgent issue, speak directly with a supervisor or manager.
• Birch Lodge: 393-6248 (leave a message after-hours)
• Copper Ridge Place: 393-7500 (leave a message after-hours)
• Macaulay Lodge: 667-5955 (leave a message after-hours)
• McDonald Lodge: 993-7704 (leave a message after-hours)
• Thomson Centre: 393-8625 (leave a message after-hours)
• Whistle Bend Place: 667-9300 (leave a message after-hours)
• Home Care: 667-5774 (during business hours only)
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