Aesculapius Award CQI initiation form
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Please use a separate form for each unique problem or suggestion: fax to 301-320-0978, page ____ of ____
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If desired, provide comparable information in a wordprocessed document by fax or by email (to hii@hii.org)
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In description, if form pertains to a document, please reference (and/or attach) relevant pages, sections, etc (marked-up as appropriate).
Report of: 
Problem Suggestion Complaint Compliment Other, specify ____________
From: Judge Entrant Sponsor Staff
Other, specify _________________________________________________________________________
Name:__________________________________________________________________________________
Tel:____________________ Fax:____________________ Email:___________________________________
Are there attachments? Yes No What is improvement priority? Critical Urgent Routine
Description of problem/complaint (no need to describe solution – we’ll investigate):
_______________________________________________________________________________________
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Suggestion/improvement/compliment (whether or not intended to resolve above-described problem; we’ll evaluate suggested improvement’s feasibility):
_______________________________________________________________________________________
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Comments:
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Only for HII use:
HII classification: Assigned CQI ID: ______________
| Processing log step | By | Date |
| Edited/Coded | _________ | __________________ |
| Entered | _________ | __________________ |
| QA’d | _________ | __________________ |