F-QM-004-A-V0 — Client Feedback, Satisfaction Survey, and Complaint Log
Type: Form · Version: V0 · Status: DRAFT — UNAPPROVED · Served read-only from the bundled QMS copies. The Drive master is untouched.
Parent document: LAB-QM-004 — Scope of Service and Laboratory User Information Policy (parent is encoded in the form number)
Rendered in-browser from the project's Word file F-QM-004-A-V0-client-feedback-survey-and-complaint-log.docx (policies-docx / forms-docx — the file Junry reviews). Formatting is faithful, not pixel-perfect; the DOCX is the official copy.
| Document # | F-QM-004-A-V0 | Parent Document | LAB-QM-004 — Scope of Service and Laboratory User Information Policy |
|---|
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# SECTION A — CLIENT FEEDBACK & COMPLAINT RECORD
Part 1 — Complainant / Client Information
| Field | Entry |
|---|---|
| Control / Tracking No. | CL-YYYY-____ |
| Date & Time Received | YYYY-MM-DD / HH:MM |
| Client / Complainant Name (Optional) | |
| Contact Information (Phone / Address) | |
| Client Category | [ ] Patient / Relative [ ] Attending Physician [ ] Nurse / Ward Staff [ ] Other: ____________ |
| Channel of Submission | [ ] Suggestion Box [ ] Reception Desk [ ] Verbal [ ] Written Letter [ ] Phone Call |
| Received by (Staff Name & Designation) |
Part 2 — Details of Concern & Immediate Containment
| Item | Description |
|---|---|
| Nature of Feedback | [ ] Turnaround Time Delay [ ] Staff Attitude / Courtesy [ ] Phlebotomy / Specimen Collection [ ] Result Reporting / Clerical [ ] Facility / Cleanliness [ ] Other |
| Specific Description of the Concern | State facts clearly, including date, shift, personnel, and clinical impact. |
| Immediate Action Taken | Immediate corrective steps taken at reception or bench to assist the client. |
| Date Complainant Acknowledged (Target <= 2 days) | YYYY-MM-DD |
| Acknowledged By | Name and Designation: ____________________________________ |
Part 3 — Investigation and Root-Cause Evaluation
| Field | Evaluation Details |
|---|---|
| Investigating Officer | Designated Complaints Officer / CMT: ________________________________ |
| Investigation Findings | |
| Quality Nonconformance Identified? | [ ] Yes (Trigger Occurrence Report F-QM-010-A-V0) [ ] No |
| Occurrence Report No. (if applicable) | |
| Root Cause / Contributing Factors |
Part 4 — Resolution, Corrective Action, and Formal Closure
| Field | Resolution Details |
|---|---|
| Corrective / Preventive Action Plan | |
| Resolution Communicated to Client (Target <= 7 days) | YYYY-MM-DD |
| Method of Communication | [ ] Verbal / In-person [ ] Phone Call [ ] Written Letter / Memorandum |
| Resolution Accepted by Client? | [ ] Yes [ ] No [ ] Unable to contact |
| Target Resolution Extension Approved By (if > 7 days) | Pathologist / CMT: ___________________ Reason: _______________________ |
| Investigating Officer Signature & Date | Signature: _________________________________ Date: _________________ |
| Chief Medical Technologist / LQM Review & Closure | Signature: _________________________________ Date: _________________ |
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# SECTION B — COMPLAINT MASTER REGISTER & TRACKING LOG
Running log of all complaints, user concerns, and grievances received by the Clinical Laboratory:
| Log No. | Date Rec'd | Complainant Name & Category | Channel | Nature of Complaint | Received By | Ack Date (<= 2d) | Action / Resolution Summary | Target Date | Resolved Date (<= 7d) | Occurrence Ref (if any) | Closed By (Initials & Date) |
|---|---|---|---|---|---|---|---|---|---|---|---|
| C-2026-01 | |||||||||||
| C-2026-02 | |||||||||||
| C-2026-03 | |||||||||||
| C-2026-04 | |||||||||||
| C-2026-05 |
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# SECTION C — CUSTOMER SATISFACTION SURVEY INSTRUMENT
Part 1 — General Survey Information
| Field | Entry |
|---|---|
| Date of Service | YYYY-MM-DD |
| Client Category | [ ] Outpatient [ ] Inpatient / Relative [ ] Physician [ ] Nurse / Ward Staff |
| Section / Service Used | [ ] Reception / Phlebotomy [ ] Hematology [ ] Clinical Microscopy [ ] Clinical Chemistry [ ] Serology |
Part 2 — Service Evaluation Matrix
Rating Scale: 5 - Excellent | 4 - Very Satisfied | 3 - Satisfied | 2 - Dissatisfied | 1 - Poor
| Dimension / Indicator | Rating (1 - 5) | Comments / Observations |
|---|---|---|
| 1. Reception & Courtesy: Staff polite, helpful, and accommodating | [ ] 5 [ ] 4 [ ] 3 [ ] 2 [ ] 1 | |
| 2. Waiting Time: Waiting time for reception and blood draw reasonable | [ ] 5 [ ] 4 [ ] 3 [ ] 2 [ ] 1 | |
| 3. Phlebotomy Experience: Blood extraction gentle, professional, and hygienic | [ ] 5 [ ] 4 [ ] 3 [ ] 2 [ ] 1 | |
| 4. Turnaround Time: Test results delivered within promised time frame | [ ] 5 [ ] 4 [ ] 3 [ ] 2 [ ] 1 | |
| 5. Facility & Cleanliness: Specimen collection area clean, safe, and organized | [ ] 5 [ ] 4 [ ] 3 [ ] 2 [ ] 1 | |
| 6. Overall Satisfaction: Overall satisfaction with diagnostic services | [ ] 5 [ ] 4 [ ] 3 [ ] 2 [ ] 1 |
Part 3 — Suggestions and Feedback
(Please share comments, commendations, or suggestions for improvement): ____________________________________________________________________________________________________ ____________________________________________________________________________________________________ (Optional) Client Name / Contact: ________________________________________________________________
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# SECTION D — QUARTERLY SATISFACTION ANALYSIS & CQI REVIEW
The Complaints Officer and CMT compile this quarterly for review in the CQI Committee and Management Review:
| Review Quarter | Total Surveys Collected | Average Satisfaction Score (1–5) | Overall Satisfaction Rate (%) | Target Met (>= 90%) | Key Areas for Improvement Identified | CQI Action Plan Initiated | Reviewed By (CMT & Pathologist) |
|---|---|---|---|---|---|---|---|
| Q1 2026 | [ ] Yes [ ] No | ||||||
| Q2 2026 | [ ] Yes [ ] No | ||||||
| Q3 2026 | [ ] Yes [ ] No | ||||||
| Q4 2026 | [ ] Yes [ ] No |