Customer Services

User Defined

NHS Professionals Feedback/Incident Form

This form takes between 5-7 minutes to complete, incomplete forms will expire within 60 minutes.

Please add your contact details and the shift reference (where applicable) to ensure accurate processing.

Client Trusts please note if you are submitting feedback regarding an NHSP bank worker (not agency worker) who has cancelled late or not attended for assignment (DNA) you will not need to submit this form.

NHSP Flexible Workers are managed through a staged process and are picked up automatically on release of Timesheets.

Thank you for taking the time to complete this Feedback Form.

Persons Involved

G.P.

Practice

S.H.A.

Other

Person Submitting Feedback (You must be band 6 or above to submit feedback.)

Your name

Reporter/Person Making Complaint

The field above is for the Staff Lookup

Job Status

Trust

Site

Address Line 2

Business Address Line 1

Address Line 3

Address Line 4

Business Address Line 4

Address Line 3

Business Address

Address Line 2

Your contact number(s)

Work Mobile

Email address

Details of person you are reporting

First Name

Surname

Job Title

Status

Grade

Staff Id

Shift Reference Number

Organisation

Site

Department

Contact No.

Ethnicity

Email Address

Post Code

Reporter/Person Providing Feedback

Staff Id

Surname

First Name

Region

Your Role

Post Code

Directorate

Ethnicity

Report/Person Making Complaint

Department Search

Property

Region

Location Lookup

Location Description

Site Type

Directorate

Specialty

Division

Feedback/Incident Details

Days Required

Initial Date Received

Case Paused

Consent Requested

Next Action Date

Response Method

Audio

Brail

Large Print

Case Number

Current Stage			Show Stages History
Next Stage

Case Type

How Received

Source

Status

Letter Date

Date Received

Shift Reference

Date of Event

Time Received

Acknowleged

Consent Received

Initial Contact Due

Initial Contact Date

Complaint Target Date

Delay Reason

Date Agreed

Final Contact

What Happened. What Actions have been taken. Any Witnesses. (Do not include any information that may identify a patient)

Please select exclusion or restriction if required

Trust

Site

Ward

Consent Required - Flexible worker consent to provide this information to the Trust

Organisation

Handler

Details of person you are reporting

Person Search

For Trust Staff Only

Please select a category.

Category Search

Type

Category

For Trust Staff Only

Head of Department Contact Details/Initial Grading/RAG Rating

In the contact details box below please enter the name and email address of your Head of Department.

Contact Detail

Severity/Likelihood

Risk Rating

Initial Score

Final Grading

Severity/Likelihood

Risk Rating

Final Score

Attachments and Documentation

Provide any statements, documents information or incident forms relating to this feedback. Please remove patient identifiable data from any documents.

Add Attachments

Document	Date Added	Time Added	Entered By	Delete

Save and Close

Please click to submit this feedback

Outcomes

Outcomes	Del.

Date Closed

Was the Enquirer Satisfied

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