customer feedback form for laboratory

Clinical and Diagnostic Laboratory Quality Assurance Feedback Form

Instructions for Use

• Please complete all sections below to assist us in maintaining our quality management system and regulatory compliance standards.
• Once completed, submit this document to the Laboratory Quality Manager via the secure portal or email address provided in Section 2.
• Your feedback is treated as confidential and will be used solely for internal process improvement and corrective action protocols.

Parties and Definitions

This Feedback Form is submitted by [Client/Patient Name] (the "Submitter") to [Laboratory Name] (the "Laboratory").

• Laboratory Reference Number: [__________]
• Date of Service: [__________]
• Test/Service Performed: [__________]

Operative Clauses

1. Nature of Feedback: The Submitter identifies the following category of feedback: [ ] Quality of Service [ ] Turnaround Time [ ] Reporting Accuracy [ ] Staff Professionalism [ ] Facility/Specimen Collection Experience [ ] Other: [__________]

2. Detailed Description: Please provide a concise, factual account of the experience or incident. If this relates to a specific specimen, please include the accession number: []. []

3. Impact Assessment: To the best of your knowledge, did this experience result in a delay of medical treatment or a clinical error? [ ] Yes [ ] No [ ] Unknown If "Yes," please describe: [__________]

4. Corrective Action Request: The Submitter [ ] requests / [ ] does not request a formal follow-up or investigation report regarding this submission. If requested, please provide preferred contact method: [__________].

5. Data Privacy and Consent: The Submitter acknowledges that the information provided herein may be processed by the Laboratory’s Quality Assurance department. The Submitter consents to the internal use of this data for compliance purposes in accordance with applicable health privacy regulations.

Signature and Acknowledgment

By signing below, I certify that the information provided is accurate to the best of my knowledge and authorized for use by the Laboratory’s quality management team.

Signature: __________ Printed Name: [] Title/Relationship: [] Date: [__________]

Legal Disclaimer: This document is a general framework intended for informational purposes only. It does not constitute legal advice. You must consult with qualified legal counsel to ensure this document complies with local, state, and federal regulations, including HIPAA, GDPR, or other relevant data privacy and clinical laboratory standards.