Comment Card - BC Cancer VICTORIA

We welcome your feedback

Online privacy & confidentiality:
This short form contains open-ended questions. We want this survey to be anonymous and we do not wish to collect any information that might identify you or a staff member in our program. We encourage you not to provide any identifying information, such as names, ages, or identification numbers, in your answers.
This comment card is for sharing the following personal information: Personal views/opinions. NOTE: do not use this form to ask treatment questions. If you are trying to reach someone about appointments or treatments, please phone 250-519-5500 or 1-800-670-3322.
Only the BC Cancer regional leadership team and the technical support team at the PHSA will access your information. The results of this survey are confidential. When results are reported, presented, or published the project team will remove personal identifiers The team may use a quote from your comments if provided. Survey data will be stored securely at PHSA for two years.

Introduction:
All of us at BC Cancer - Victoria recognize the importance of providing the highest standard of care, treatment and service. We also believe in providing a high quality work environment for our staff. We are constantly evaluating our performance. Did we meet your needs? Your concerns? Your expectations? Did we fall short or exceed in some areas?
We value your suggestions and comments. Please take a moment to write your comments in this form. It will be delivered to us when you click "Finish" at the end.

I am a:

	Community member / Local resident / Donor
	Family member
	Friend / Supporter of a patient
	Patient
	Staff member / Healthcare provider
	Other:

Topic

What patient visit did you want to comment about?

	Chemotherapy (Systemic therapy)
	Follow up appointment
	New Patient - first consult
	PET/CT
	Radiation therapy
	RT - Brachytherapy
	Support programs e.g. Counseling, Nutrition, Library
	Staff / Employee feedback
	Other:

This box is for your comments.

For example, you might want to say thank you or send a compliment to particular staff.
You are not required to share any private or confidential information on this form.
If you have a question about your own cancer care, such as appointments, please contact your care team instead.

Thank you for your co-operation and assistance in providing your feedback. All comments will be kept in strict confidence.

If you want a personal reply, please agree to be contacted, by checking the button below.

I consent to be contacted to follow-up on my comments.

	Yes
	No

Are you interested in being on the Regional Patient Experience Committee which provides input into the operations of BC Cancer - Victoria?

You may visit the BC Cancer Patient / Family Partners page to register, or check the box below to be contacted in person.

	Yes, please contact me about joining the Regional Patient Experience Committee
	No, thanks

Thank you, again, for providing your comments.
This feedback form will be sent when you click the "Finish" button below.

Your personal information is collected under the authority of s. 26(e) of FIPPA. This information will be used for the purpose of planning or evaluating of BC Cancer - Victoria services. All responses will be kept confidential within BC Cancer and will be maintained securely. For questions about this form, please contact the BC Cancer - Victoria Library by email (Librarian, L. Leitz).
For questions or concerns about privacy, please visit http://www.phsa.ca/privacy or contact privacyandfoi@phsa.ca