We Care
Care Provider/Location:
Date of Visit:
Would you like to be contacted about any concerns? Yes No
Name: ___________________________________
Address: _________________________________
_________________________________________
Phone: __________________________________
Northern Cheyenne Service Unit
We value your opinion. Thank you for taking a moment to let us know about your visit today.
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How was our customer service today?
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How was your wait time?
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How did your team perform today?
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How were your needs met today?
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How was your overall experience today?
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Date Received by Risk Management Department _______________ Assigned Tracking Number _____________
Date Referred on for further investigation _____________________ Date Investigation Completed __________
Referred to: ______________________________________________
Date Returned to Risk Management Department ________________ Complainant Contacted on _____________
Date Closed ____________________________________________ □ Phone □ Letter □ Email
Comments: _____________________________________________________________________________________________
________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ ___________
______________________________________________________________________________________________________________________________________________________________________________________________________________
| File Type | application/vnd.ms-office |
| Author | Tallbull, Cheyenne (IHS/BIL) |
| File Modified | 0000-00-00 |
| File Created | 0000-00-00 |