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Exit Survey
 
 
You must print this form and have it signed by your supervisor BEFORE submitting

 
 
 
 
Name
   
 
 
* Department where incident/complaint occured
 
 
* Was this a Patient or Patient guest complaint?
 
Patient
 
Guest
 
 
* What was the Patient status
 
Inpatient
 
Outpatient
 
 
* Method of complaint
 
In person
 
Phone
 
Letter
 
Email
 
Other
 
 
 
* Incident/Complaint Category
 
 
* Describe incident/complaint
   
 
 
* Your follow up action
   
 
 
* Do you feel the Patient/Patient guest was satisfied?
 
Yes
 
No
 
 
* Is further follow up necessary?
 
Yes
 
No
You must print this form and have it signed by your supervisor BEFORE submitting