SHS Feedback Form SHS Feedback Form I am a:* Student Parent or guardian BU faculty or staff Please choose the department you visited or interacted with:*Primary CarePrimary Care – LabPrimary Care – COVID-19 IssueImmunization ClinicCounseling & Psychiatric Services (CAPS)Health Promotion & PreventionSARPAthletic TrainingPatient Services (front desk)Student Health Insurance PlanPatient Connect websiteDate of experience (if applicable) MM slash DD slash YYYY I would like to report a: Positive experience Negative experience Suggestion for improvement or idea Tell us what went well?*Please share your suggestions for improvement or ideas.*Please describe the problemHow would you describe the nature of the problem you experienced? Please check all that apply. Access to Care Long wait time Unable to obtain services from a specific provider Unable to obtain a specific type of treatment Request for service denied by provider Location not physically accessible or welcoming (e.g. not enough chairs or parking) Customer Service/Attitude Provider does not return calls or messages Rude treatment or lack of courtesy by health care provider or staff Incorrect information provided Cultural Sensitivity Insensitivity to cultural/language needs Lack of diversity among providers or staff Lack of providers who speak diverse languages Unable to obtain translation service Provider did not use my correct pronouns or preferred name Gender affirming healthcare concern Billing Issues I was billed more than I anticipated Problem with Aetna Student Health Insurance Plan Other insurance issue (non SHIP plan) Healthcare Quality Dissatisfaction with treatment plan or outcome Improper testing or test results not given Medication error Misdiagnosis Provider said something that made me feel uncomfortable Provider touched me in a way that made me feel uncomfortable Breach of privacy or confidentiality Dissatisfaction with protocol or process Website/Patient Connect Student website/portal issue Incorrect information on website Other – Please DescribePlease tell us more?If you like, please provide additional details (for example, name of provider, problems with treatment, etc.) What outcomes or expectations did you anticipate that were not met?Would you like to change providers?If yes, please consider selecting “yes” for follow up contact about this issue, so that we may assist you, or send a message in Patient Connect requesting that you be assigned to a new provider. Yes No N/A Would you like to be contacted for follow-up?If yes, please provide your preferred contact method. To remain anonymous, choose no. Yes No Name* First Last BU ID Number* Preferred Contact Method Email Phone Email PhoneCAPTCHACommentsThis field is for validation purposes and should be left unchanged.