Feedback Form

For internal use to make a record of calls or feedback concerning complaints, compliments, kudos, observations, or any comments reported (positive or negative) particularly as it concerns Still Waters employees. (Example: Counselors and Office Staff)

MM slash DD slash YYYY
2. Feedback Method

Information about who communicated the feedback?

3. Name of person who communicated feedback:
4_a. Select the person's (giving feedback) relationship to Still Waters:
List name of Organization/Company if applies)
If the person giving feedback represents an organization or company please list the name. Example: Columbia County DFCS

Feedback about information

This section describes who the feedback is about or concerning.
7_a. Who or what was the feedback concerning?
8_a. Name of person that feedback was about:
If the name of the person is unknown, describe in 8_b. any details so that the person can potentially be identified.
Example: The person was a short female with long brown hair, her office was upstairs.

Feedback

9_a. Feedback selections:
Select all that apply. Note: Answer the details behind the selection in 9_c. If the selections do not describe the feedback, select "other" and describe in 9_c.
9_b. Requests:
Select all that apply. Note: Answer the details behind the selection in 9_c.
Describe with as many details as possible. Use the questions behind the selection to describe.

Person documenting the feedback:

Name of person documenting feedback