Feedback Survey

About you

Q1. Are you contacting us to discuss a personal health issue or concern? *

NoYes

Please exit the survey and contact your health practitioner directly as we cannot provide advice about health issues.

EXIT SURVEY

Q2. Are you providing this feedback on behalf of an organisation that we fund (commission) to deliver health services? *

NoYes

Is your feedback related to the organisation's contract with CCQ in any way? *

NoYes

Please refer to you Service Order for the appropriate CCQ officer to contact and do not provide your feedback here.

EXIT SURVEY

Q3. Are you completing this form on behalf of someone else? *

No, I am completing this form for myselfYes

Are you a CCQ staff member? *

NoYes

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Please provide more information so that we can respond to the person's feedback appropriately.

Name (or alias) of the person for whom you are completing this form

Your relationship to the person

Organisation you work for (only if you are representing the person in a professional capacity)

Has the person given their consent for you to represent them in relation to this issue?

Yes, they have asked me to represent themNo, I'm just helping them complete the formNo, the person is my dependent or otherwise unable to give consent directly

Who should we contact for more information or to follow up this feedback?

Contact meContact the person for whom I am completing this form

Your name

Your email

Your phone no.

Their phone no.

Their email

Q5. Please choose one of the following options

I wish to remain anonymous. I understand that as a result of withholding my personal details, CCQ will not be able to contact me about this feedbackI consent to CCQ contacting me about this feedback (we'll contact you if we need more information or to tell you how we've responded to your feedback)

Your name

Your email

Your phone no.

Feedback details

Help us direct this feedback to the right people in our team by selecting one or more feedback topicsbelow.

Q6. Feedback Topics:

CCQ’s information resources (e.g. website, publications, training materials, social media)The support we provide to primary health practitioners and practicesThe actions/behaviour of a CCQ employee/sThe quality, safety or accessibility of a service or program that CCQ funds The quality, safety or accessibility of health services in our region CCQ’s professional development, training and networking activities for health practitionersOur community consultation and stakeholder engagement Our tender processesPrivacy concerns – how CCQ has collected, stored, used or disclosed personal informationSomething else

Q7. Is your feedback...?

A complimentA suggestionA complaintA comment or observationAnother type of feedback

Q8. Okay, over to you. Please tell us want you want us to know.

NB. If you have a complaint about an incident or issue and would like us to investigate it, please provide as much information as possible, like:

• what happened

• where and when it happened, i.e., date, time, place etc

• who was involved

• what your main concern is about what happened

• what you have done already to try to fix the problem (if applicable)

• any other information that will help us to respond to or investigate your feedback.

Resolution

Q9. Please tell us what you (or the person for whom you are completing this form) would like to have happen as a result of providing this feedback.

Nothing – happy with things as they are To have this feedback considered in improving CCQ’s services or resourcesTo have this feedback considered in improving health or community services that CCQ funds/commissionsTo have a decision reviewed To have CCQ change a policy or process To receive an explanation for a decision/actionTo have a complaint investigatedTo receive an apology Something else

Please tell us more:

Supporting documents

Q10. Please attach any documents, photos or other evidence relating to this feedback.

Browse

Submission

Please email me a copy of my completed feedback form

Email address

TIP - If you don't receive an email, check your spam folder.

Thank you so much for taking the time to share your feedback with us, or help someone else to.

Only together we can make a difference. 

If you have provided your contact details, we will be in touch shortly.

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SUBMIT