"Feedback Form" - Nunavut, Canada

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Feedback Form
Office of Patient Relations
The Office of Patient Relations, Department of Health, Government
1) Acknowledge receipt of Feedback Form within 48
of Nunavut is responsible for investigating and resolving conflicts
business hours and send a copy of your completed form
between patients and healthcare providers as well as sharing
to the appropriate Health Official and regional point
positive patient experiences with the appropriate members of
person closest to the healthcare provider in question to
your healthcare team. The investigation process may include
obtain a response.
disclosure of personal identifiable information related to your
2) Contact other individuals and/or institutions named in
health records. The process time can vary depending on the
your completed form that may have information relevant
severity of the issue.
to your issue.
3) Review all information received.
To begin an inquiry into your complaint, please complete this form
4) Provide you with either a written or verbal response to the
THE PROCESS
and attach any additional information or descriptions you want
review depending on complexity.
included that are related to your case.
If you have any questions or need help completing this form,
Please fax, email or mail this form to the Office of
please contact the Territorial Manager of Patient Relations at
Patient Relations.
1-855-438-3003.
Once the document is received – the Office of Patient
For more information please visit:
Relations will then:
www.patientrelations.gov.nu.ca
Information from the person making the complaint:
1
Ms
Mrs
Mr
Dr
(first name)
(last name)
Address
City
Postal Code
Email
Telephone number with area code where we can contact you during the day (8:30 a.m. - 5:00 p.m. Monday to Friday)
(
)
(
)
Mobile (
)
Home
Work
(If you are filing this complaint on behalf of the patient, please provide a copy of the documentation authorizing your permission.
Examples include - executor of an estate, legal guardian, or patient’s written consent)
Patient information
2
Birth Date (dd/mmm/yyyy)
Nunavut Health Care #
 Address information same as above
Ms
Mrs
Mr
Dr
(first name)
(last name)
Address
City
Postal Code
Email
Telephone number with area code where we can contact the patient during the day (8:30 a.m. - 5:00 p.m.
Monday to Friday)
(
)
(
)
Mobile (
)
Home
Work
1/2
Feedback Form
Office of Patient Relations
The Office of Patient Relations, Department of Health, Government
1) Acknowledge receipt of Feedback Form within 48
of Nunavut is responsible for investigating and resolving conflicts
business hours and send a copy of your completed form
between patients and healthcare providers as well as sharing
to the appropriate Health Official and regional point
positive patient experiences with the appropriate members of
person closest to the healthcare provider in question to
your healthcare team. The investigation process may include
obtain a response.
disclosure of personal identifiable information related to your
2) Contact other individuals and/or institutions named in
health records. The process time can vary depending on the
your completed form that may have information relevant
severity of the issue.
to your issue.
3) Review all information received.
To begin an inquiry into your complaint, please complete this form
4) Provide you with either a written or verbal response to the
THE PROCESS
and attach any additional information or descriptions you want
review depending on complexity.
included that are related to your case.
If you have any questions or need help completing this form,
Please fax, email or mail this form to the Office of
please contact the Territorial Manager of Patient Relations at
Patient Relations.
1-855-438-3003.
Once the document is received – the Office of Patient
For more information please visit:
Relations will then:
www.patientrelations.gov.nu.ca
Information from the person making the complaint:
1
Ms
Mrs
Mr
Dr
(first name)
(last name)
Address
City
Postal Code
Email
Telephone number with area code where we can contact you during the day (8:30 a.m. - 5:00 p.m. Monday to Friday)
(
)
(
)
Mobile (
)
Home
Work
(If you are filing this complaint on behalf of the patient, please provide a copy of the documentation authorizing your permission.
Examples include - executor of an estate, legal guardian, or patient’s written consent)
Patient information
2
Birth Date (dd/mmm/yyyy)
Nunavut Health Care #
 Address information same as above
Ms
Mrs
Mr
Dr
(first name)
(last name)
Address
City
Postal Code
Email
Telephone number with area code where we can contact the patient during the day (8:30 a.m. - 5:00 p.m.
Monday to Friday)
(
)
(
)
Mobile (
)
Home
Work
1/2
Provide a clear description of the complaint(s) you have about the health service or
provider(s). Please include in your description what the healthcare provider did or
3
failed to do to cause your concern, including:
1.
What happened?
2.
Where did this incident take place?
3.
Date and approximate time of incident:
4.
What do you hope will happen as a result of your concern?
Please attach any relevant information that will assist in this inquiry.
Signature of person making complaint
Date signed (dd/mm/yyyy)
I understand my signature on this release allows the Department of Health and Social Services, Government of Nunavut where
applicable to
1. Obtain medical records or other information, as specified in the case description, relevant to my issue(s)
2. Provide a copy of my formal complaint to the healthcare provider named in order to obtain a response
3. Disclose, where applicable, information concerning my complaint including person identifiable information, diagnostic,
treatment and care information to the person making the complaint on my behalf.
Completion of this form remains confidential, as otherwise indicated above.
Signature of Patient
Date signed (dd/mm/yyyy)
If the patient is deceased, please provide the date
of death
Our Address:
Department of Health
Office of Patient Relations
P.O. Box 1000, Station 1050
Date of death (dd/mm/yyyy)
Iqaluit, Nunavut X0A 0H0
1-855-438-3003
867-975-5388
patientrelations@gov.nu.ca
www.patientrelations.gov.nu.ca
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