Feedback Form

Details of Feedback

Name of person affected:

Ethnicity of person affected (as reported by the person affected):

If Other, please enter below

Nature of Feedback:*

Which department of NMDHB are you giving feedback about?

When did the event occur?

If exact date is unknown, indicate approx. time frame:

Would you like to be contacted about this so that the matter can be further addressed?:

Details of Person Giving Feedback

Name:*

Address:*

Email:*

Home Phone:

Work Phone:

Best time of day to contact you:

Best place to contact you:

Who are you?:

If you are giving the feedback on behalf of another person, is that person aware that the comment is being made?:

* Required