Current Page 1 Preview Personal information on this form is collected under the authority of Section 31(c) of the Freedom of Information and Protection of Privacy Act and will be used for the purposes of resolving or responding to your compliment or complaint. Questions on the collection and use of this information can be directed to Health PEI at firstname.lastname@example.org. Identification What type of feedback are you providing? - Select -ComplimentComplaint First Name Last Name Do you wish us to contact you? - Select -YesNo Email Address You will receive a confirmation of this submission to the email you provide here. If you indicated that you wish us to contact you, we will use this email address. Please make sure it is entered correctly. Telephone Number For example 902-555-5555 Compliments and Complaints Date event occurred For example: yyyy-mm-dd Facility/site where event occurred Example: QEH, Colville Manor, Harbourside Health Centre, etc. Location of event Example: Unit 1, Emergency Department, Diagnostic Imaging, Medical Clinic, etc. What is the nature of your compliment or complaint? - Select -Access to serviceAttitude/CourtesyCare/TreatmentCommunicationConcern related to treatmentEnvironmentWait TimeOther Other, please specify. Describe the event. What happened and the order in which things happened. Where possible, include dates and list any phone calls, letters or meetings that took place. Describe what action you would like taken. Math question 1 + 1 = Solve this simple math problem and enter the result. E.g. for 1+3, enter 4.