Quality of health information on the Internet (QHII)
Continuous Quality Improvement

Health Improvement Institute welcomes suggestions to improve its programs and projects! To suggest an improvement (or to report a problem or to register a complaint or compliment), please:

Please print, complete, & fax this page to 301-320-0978 - page 1 of _____
If suggestion, etc pertains to a document, please attach relevant (marked up) pages

Report of: Problem Suggestion Complaint Compliment Other, specify ____________
From:
Participant Rater Sponsor Other, specify ____________

Name:__________________________________________________________________________________

Tel:____________________ Fax:____________________ Email:___________________________________

Are there attachments?
Yes No What is improvement priority? Critical Urgent Routine
Description of problem/complaint (no need to describe solution – we’ll investigate):
_______________________________________________________________________________________

_______________________________________________________________________________________

_______________________________________________________________________________________

Suggestion/improvement/compliment (whether or not intended to resolve above-described problem; we’ll evaluate suggested improvement’s feasibility):
_______________________________________________________________________________________

_______________________________________________________________________________________

_______________________________________________________________________________________

Please attach sheet with any additional requests.


Only for HII use:
HII classification: Assigned CQI ID: ______________
Processing log step By Date
Edited/Coded _________ __________________
Entered _________ __________________
QA’d _________ __________________
Actioned _________ __________________

version 1.3 – September 21, 2007