KBTH Feedback Notification Form.
KBTH seeks to improve upon the experience of care received by its cherished clients/patients. This form therefore seeks to solicit feedback from you on the quality of care you received during your journey to enable us continuously improve upon our services. Thank you for your feedback.
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Kindly indicate the kind of feedback/concern you would like to share with us? *
Category of individual giving feedback *
Age *
Gender *
What is your highest level of education? *
Marital status *
What is your occupation? *
Religion *
Residence (Community in which you stay) *
Department *
Kindly indicate the Unit/Floor in which you are on.
Status of patient (or person completing the form) *
Is today the first time you are receiving care in this hospital? *
What was your first reaction when you were referred to KBTH for further care? *
Kindly provide a brief narrative or description of your  feedback (compliment, complaint or suggestion) or any concern with the service you have received. *
Date of incident *
MM
/
DD
/
YYYY
Time of incident *
Time
:
Kindly rate your level of satisfaction on a scale of 1 to 4 *
Will you recommend KBTH to any of your relatives, friends or loved ones whenever they need to access healthcare? *
Would you like to be contacted? *
Phone number
E-mail address
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