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Questionnaire template

Hospital Patient Complaint Form

Collects patients' complaints about hospital services, the departments and staff involved, and follow-up preferences.

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Questions in this template

About Your Visit

  1. We are sorry that something about your care fell short. This form lets you tell us what happened so we can look into it and improve.

  2. Which parts of the hospital did you receive care from on your most recent visit? Select all that apply.

    Choose any that apply:

    • Emergency department
    • Radiology and imaging
    • Outpatient clinics
    • Intensive care
    • Pharmacy
    • Other

  3. Which other department?

    Condition: Shown when Other was selected

    Open answer

  4. Overall, how satisfied were you with the care and service you received?

    Choose one:

    • Very satisfied
    • Somewhat satisfied
    • Neither satisfied nor dissatisfied
    • Somewhat dissatisfied
    • Very dissatisfied

  5. On a scale from 1 (very poor) to 10 (excellent), how would you rate each of these?

    • Quality of care
    • How staff communicated with you
    • Respect for your privacy
    • Cleanliness
    • Waiting times

    For each row: choose one:

    • 1 - Very poor
    • 2
    • 3
    • 4
    • 5
    • 6
    • 7
    • 8
    • 9
    • 10 - Excellent

Your Complaint

  1. Please describe what went wrong, including when it happened and anything that would help us understand it.

    Open answer

  2. Is your complaint about a particular department?

    Choose one:

    • Yes
    • No

  3. Which department or departments is it about? Select all that apply.

    Condition: Only if the complaint concerns a department

    Choose any that apply:

    • Emergency department
    • Radiology and imaging
    • Outpatient clinics
    • Intensive care
    • Pharmacy
    • Other

  4. Is your complaint about a particular member of staff?

    Choose one:

    • Yes
    • No

  5. If you know them, please give the staff member's name and role.

    Condition: Only if the complaint concerns a staff member

    Open answer

Earlier Complaints and Follow-up

  1. Have you complained about this matter before?

    Choose one:

    • Yes
    • No

  2. If you have it, what was the reference number of your earlier complaint?

    Condition: Only if you complained before

    Open answer

  3. What happened after your earlier complaint, and what do you feel was left undone?

    Condition: Only if you complained before

    Open answer

  4. Would you like us to contact you about this complaint?

    Choose one:

    • Yes
    • No

  5. How should we reach you? Please give an email address or phone number.

    Condition: Only if you would like to be contacted

    Open answer