Health Improvement Institute welcomes suggestions to improve its programs and projects! To suggest an improvement (or to report a problem or to register a complaint or compliment), please:

• Complete and fax this form; use a separate form for each suggestion, etc
• Send equivalent information in an email to hii@hii.org
• Call the Awards Coordinator at 301-320-0971
• Write to us

Report of:

Sponsor 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):
_______________________________________________________________________________________

_______________________________________________________________________________________

_______________________________________________________________________________________

Suggestion/improvement/compliment (whether or not intended to resolve above-described problem; we’ll evaluate suggested improvement’s feasibility):
_______________________________________________________________________________________

_______________________________________________________________________________________

_______________________________________________________________________________________

Please attach sheet with any additional requests.


Only for HII use:
HII classification: Assigned CQI ID: ______________

Processing log step	By	Date
Edited/Coded	_________	__________________
Entered	_________	__________________
QA’d	_________	__________________

Actioned

_________

__________________

version 1.3 – September 21, 2007

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