Engage System - Feedback Input

Patient Feedback Form

Robert Wood Johnson University Hospital Hamilton employees can use this page to enter feedback on behalf of customers. Feedback will be aggregated and automatically routed to the appropriate Robert Wood Johnson University Hospital Hamilton manager.

If you have questions or comments about this system, want to find out the status of an item you entered, or want to add additional comments to an item, please contact your manager.

Feedback Classification

Please select the type of feedback:

Please select the feedback source:

This feedback is about:

select

Employee Information

* Employee name:
Employee e-mail address:	(Items marked with an (*) asterisk are required)

Feedback Information

From the patient's perspective, what is the COMPLAINT regarding?

Is there an internal category for this COMPLAINT?

Please describe the COMPLAINT.


	(Information entered in this field MAY BE viewable by the patient.)

What would the patient like done to resolve this issue?


	(Information entered in this field MAY BE viewable by the patient.)

Is this regarding a particular employee? If yes, input employee name. If no or unsure, leave blank.

Estimate the date of service.

Open the calendar popup.

(Date format : mm/dd/yyyy)

Patient Information

(Please provide as much information as you can. If feedback is from someone who is not a patient, please make note of it in the Feedback Information section.)

First name:
Last Name	(if business account, input Last name/business name. ex: Smith / Acme Co.)
Address line 1:
Address line 2:
City:
State:
Zip code:
Phone:
E-mail address:
Patient requires additional follow-up: (If yes, please provide the appropriate contact information in the fields above.)	Yes No
Patient prefers future contact regarding this feedback via:	E-mail Phone Letter In Person

Your Notes

Enter the details of anything you did to resolve the issue, start the resolution process, or respond to the patient.

Resolution/Notes:


	(Information entered in this field WILL NOT be viewable by the patient.)

Attachment (optional):

(Maximum file size limit 8 MB)
(Supported Files: 'pdf','jpg','txt','jpeg','gif','csv','docx','doc','xlsx','xls','img', 'pptx','bmp','png')