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Required format:

Feedback Submission Form

Please complete this secure form to submit your care concerns or feedback electronically.

The personal information requested on this form and any additional information required by the Patient Care Quality Office in reviewing the care quality complaint submitted by or on behalf of an individual is collected under the authority of the Patient Care Quality Review Board Act and section 26(c) the Freedom of Information and Protection of Privacy Act, and will be used only for the purpose of reviewing this complaint. All persons obtaining personal information under the Patient Care Quality Review Board Act are under a duty of confidentiality with respect to that information. The authorization you complete below becomes effective on the date this form is submitted and remains in effect until the review is completed.

If you have any questions about the collection, use or disclosure of this information please contact the:

Patient Care Quality Office
Royal Jubilee Hospital
Memorial Pavilion
Watson Wing, Rm 315
1952 Bay Street
Victoria, B.C.
V8R 1J8

250-370-8323
Toll-free: 1-877-977-5797
Fax: 250-370-8137

patientcarequalityoffice@islandhealth.ca

Your Full Name

Mailing Address

Phone Number

Email Address

At this time all the Health Authorities in BC are asking patients and clients with Indigenous ancestry if they would like to self identify as Indigenous such as First Nation, non-status First Nation, Métis or Inuit. Self identification is voluntary, you do not have to provide proof, the answer will not affect the care or service you receive, and you can choose not to answer. The purpose of identifying is to ensure we can learn about the health perspectives affecting Indigenous populations, and possibly connect them with supports to local resources. All information is completely confidential and protected by the Freedom of Information and Protection of Privacy Act. Please let me know if you would like to self identify as Indigenous at this time

Yes

Decline to Answer

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Which Indigenous group do you identify with?

First Nation

Inuit

Métis

Other

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Other

How do you prefer we contact you?

Mail

Phone

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Are you the client, patient or resident who received the care or services?

* must provide value

Yes

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Supporting Documentation

If you are submitting a concern on behalf of someone else, under the stipulations of the Freedom of Information and Protection of Privacy Act, we require their direct consent or to be provided applicable documentation that you have the authority to act on their behalf. Documentation in the form of a Health Representation Agreement (Rep 9) or a Will that names you as the executor.

If you are unable or do not wish to upload these documents via this platform, the Liaison assigned to your file will discuss consent requirements with you upon direct contact.

Upload file

Client, Patient, Resident: Full Name

Client, Patient, Resident: Date of Birth

D-M-Y

What is your relationship to the patient?

Is the Patient/Client currently in hospital or care?

Yes

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Is this concern about active care that requires immediate support from PCQO?

Yes

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Location (Island Health Facility) of Care or Services

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Date of Service

D-M-Y

Summary of concerns or feedback

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Was your concern addressed at the time and place it occurred?

Yes

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Optional: Please provide the name and title of who it was addressed by.

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How can we help address your concern?

I would like to be contacted

Submit as feedback only

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A Liaison will be in contact with you as soon as possible to go over our process and discuss your concern.

The Patient Care Quality Office takes the feedback you provided very seriously and we will forward it on to the appropriate program for their information. You will not be contacted.

Is there any other important information you would like to share?

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