Ethics Consultation Feedback Form
Please provide your feedback regarding your recent ethics consultation experience. Your input helps us improve our services.
Your Role in the Consultation
*
Patient/Client
Family Member/Support Person
Healthcare Provider
Ethics Committee Member
Other
Date of Ethics Consultation
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Consultation Type
*
Please Select
In-person
Virtual/Telehealth
Phone
Written/Email
Other
Case ID or Subject (if applicable)
How did you request or become involved in the ethics consultation?
Please rate the following aspects of the ethics consultation:
*
Rows
Excellent
Good
Fair
Poor
Clarity of information provided
1
2
3
4
Impartiality of the consultant(s)
5
6
7
8
Respect for all parties involved
9
10
11
12
Communication and responsiveness
13
14
15
16
Helpfulness of recommendations
17
18
19
20
Overall, how satisfied are you with the ethics consultation?
*
1
2
3
4
5
Were your concerns addressed adequately during the consultation?
*
Yes, completely
Yes, somewhat
No, not really
No, not at all
What did you find most helpful about the ethics consultation?
What suggestions do you have for improving the ethics consultation process?
May we use your feedback (anonymously) for quality improvement and training purposes?
*
Yes, you may use my feedback anonymously.
No, please do not use my feedback.
If you would like us to follow up with you regarding your feedback, please provide your email address (optional):
example@example.com
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