UCSB Health Feedback Form 
This form is a place to share experiences or feedback regarding healthcare you have obtained or attempted to obtain on UCSB's campus which will be used by the Health Equity Advocate, Buster Buchanan (he/him), to ascertain weak points in UCSB's healthcare systems and advocate on behalf of students. You may provide feedback about Student Health, CAPS, Health and Wellness, or any other health related campus. All questions are optional and you may provide as much or as little information as you want. You may remain anonymous if you choose.

For the purpose of this form, an instance of health inequity includes any experience in the process of obtaining healthcare that makes an individual feel uncomfortable, concerned, ignored, uncared for, or discouraged from receiving further/future care. Things to report here can include misgendering, deadnaming, medical bias, refusal to treat, provider's use of harmful stereotypes, inaccessibility of care, website/online/promotional inaccuracies, discrimination due to identity or appearance, or any other form of health discrimination a student may encounter while pursuing healthcare at UCSB. 

Thank you for sharing your words and if you have any questions or would like to talk with someone regarding your experiences, please reach out to Buster at buchanan856@ucsb.eduThis form is not directly affiliated with Student Health. If you would like to provide feedback directly to Student Health, please fill out their Student Health Survey. 

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Approximately when did you experience or become aware of this issue? (ex: 4 years ago, fall 2022, December 15th 2020)
What is the approximate location that your feedback pertains to? (ex: SHS lab, CAPS website, gender care, etc.)
What would you like to report/share? (Please provide as much detail as you are comfortable with)
Would you like the Health Equity Advocate/UCSB to respond to your feedback in a specific way? (request action, suggest solutions, etc.)
Would you like our Health Equity Advocate to follow-up with you regarding your feedback?
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Lived name, pronouns, and UCSB email (optional and will only be used for follow-up)
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