2018 TRN Grievance Poster Feedback Form

1. The 2018 TRN Grievance Poster is easy to understand:

Very Much

Somewhat

A little

Not at all

2. The design of the 2018 TRN Grievance Poster is attractive:

Very Much

Somewhat

A little

Not at all

3. How have you used the TRN Grievance Poster (please check all that apply):

It has been posted in the waiting room

Flyers have been distributed to patients

Other:

If you chose other, please describe:

4. Would you like a copy of the Grievance Poster in Spanish?

Yes

No

If you chose yes, how many?

5. In December, we emailed out a Flyer on how to identify what a grievance is. If you distributed these flyers to patients, how many?

1-25

26-50

51-75

Over 75

6. Would you like hard copies of the Flyer sent to you? (please mark down how many)

Yes2

No2

If you chose yes, please let us know how many copies you would like:

7. In what other ways will you use the resources provided (Poster and Flyer): (Please check all that apply):

Share information about the Network grievance process at a staff meeting

Talk individually to patients about it

Share resources at a Patient Lobby Day

Other

If you chose other, please describe:

8. Are there other types of resources you would like to assist you with grievance and/or conflict resolution?

9. Additional Comments:

10. If you would like more copies of the poster sent to you (please indicate below), posters in spanish, and/or flyers sent to you - Please included your contact information below:

Send me a copy of my responses