Client Feedback Form by YF3Th7w0

VIEWS: 63 PAGES: 3

									                                                                      Please return completed form to:
                                                                                                              Real Community Services
                                                                                                              Po Box 1249
                                                                                                              Oxley QLD 4075
                                                                                                              Fax: 07 3278 1522


Feedback Form
We aim to ensure that all staff and stakeholders of Real Community Services, (RCS) feel comfortable giving us feedback whether it be a
concern, complaint, compliment or a suggestion. Your feedback is important to us as it helps us improve our services.

Please be aware that all complaints, concerns and suggestions are always treated as confidential and RCS ensures that all
clients/staff/stakeholders:

       o     Receive support when reporting a complaint or dispute;
       o     Are encouraged to raise any problems or complaints they have without fear of punishment or retribution;
       o     Are listened to, treated with respect and have their concerns/feedback addressed within agreed time frames.
You may have an idea or suggestion that will help us make positive changes to service delivery, if so we certainly need to hear about it!

What type of feedback would you like to give us?

Positive feedback for our service:                   Complaint about our service:

Concern about our service:                            Suggestion to improve our service:




Details of person completing this form:

Full Name: ____________________________________

Service/Organisation: (if applicable)_______________________

Telephone No: _________________________________

    Client/Consumer                  Staff Member                   Relative                  Other __________________________

Feedback Made in Relation To:

    Client/Consumer           Service Provision         Staff Member           Other____________________________

Name/s of People Involved (if applicable):

Brief Description of Feedback: (Provide additional pages if needed)




                                                                Page 1 of 3
RCS.SDS.F14                                                                                                                 ISSUE NO: 06
FEEDBACK FORM                                                                                                               DATE: JUL 11
                                                                 Please return completed form to:
                                                                                                     Real Community Services
                                                                                                     Po Box 1249
                                                                                                     Oxley QLD 4075
                                                                                                     Fax: 07 3278 1522



Office Use ONLY                                                                     Reference Number: CCF_____/__
To be completed by person responding to feedback

Name:                                                             Position:

Date Received:                                                    Signature:

Method of Feedback:

   In Person             In Writing           Telephone               Other




Classification of Feedback:

   Quality of Service             Lack of Resources             Funding                 Service Eligibility

   Communication                  Staff Conduct                 Client Conduct          Co-Resident Conduct

   Other (please specify) __________________________________________

Outcome:

What action was taken?
   Investigation                                  Service Level Resolution
   Mediation                                      Rejected (Grounds for rejection if applicable): ___________________
What was the remedy?
   Apology                                    Explanation
   Decision changed                           System change
   Policy identified for review               Resources increased                                                               Servi
   Staff training/development                 Referral
   Staff Discipline                           Resources decreased
   Service increased                          Other (please specify):___________________________________

Summary of Action Taken & Outcomes




                                                            Page 2 of 3
RCS.SDS.F14                                                                                                      ISSUE NO: 06
FEEDBACK FORM                                                                                                    DATE: JUL 11
                                                        Please return completed form to:
                                                                                           Real Community Services
                                                                                           Po Box 1249
                                                                                           Oxley QLD 4075
                                                                                           Fax: 07 3278 1522

Follow-Up Required

Manager notified                                                           Yes       No      N/A    Date:
Managing Director notified                                                 Yes       No      N/A    Date:
WHSO notified                                                              Yes       No      N/A    Date:
Client/Client’s family notified                                            Yes       No      N/A    Date:
Client advocate notified                                                   Yes       No      N/A    Date:
Concern/Complaint/Feedback recorded in register                            Yes       No      N/A    Date:




             Processed by:
             Name: ___________________________                   Date Received: ____________________
             Position: _________________________
             Signature: ________________________________         Date Closed: ______________________




                                                   Page 3 of 3
RCS.SDS.F14                                                                                            ISSUE NO: 06
FEEDBACK FORM                                                                                          DATE: JUL 11

								
To top