{"id":2563,"date":"2025-07-09T16:17:11","date_gmt":"2025-07-09T20:17:11","guid":{"rendered":"https:\/\/www.bu.edu\/shs\/?page_id=2563"},"modified":"2025-07-09T16:17:48","modified_gmt":"2025-07-09T20:17:48","slug":"shs-feedback-form","status":"publish","type":"page","link":"https:\/\/www.bu.edu\/shs\/shs-feedback-form\/","title":{"rendered":"SHS Feedback Form"},"content":{"rendered":"<script type=\"text\/javascript\">var gform;gform||(document.addEventListener(\"gform_main_scripts_loaded\",function(){gform.scriptsLoaded=!0}),window.addEventListener(\"DOMContentLoaded\",function(){gform.domLoaded=!0}),gform={domLoaded:!1,scriptsLoaded:!1,initializeOnLoaded:function(o){gform.domLoaded&&gform.scriptsLoaded?o():!gform.domLoaded&&gform.scriptsLoaded?window.addEventListener(\"DOMContentLoaded\",o):document.addEventListener(\"gform_main_scripts_loaded\",o)},hooks:{action:{},filter:{}},addAction:function(o,n,r,t){gform.addHook(\"action\",o,n,r,t)},addFilter:function(o,n,r,t){gform.addHook(\"filter\",o,n,r,t)},doAction:function(o){gform.doHook(\"action\",o,arguments)},applyFilters:function(o){return gform.doHook(\"filter\",o,arguments)},removeAction:function(o,n){gform.removeHook(\"action\",o,n)},removeFilter:function(o,n,r){gform.removeHook(\"filter\",o,n,r)},addHook:function(o,n,r,t,i){null==gform.hooks[o][n]&&(gform.hooks[o][n]=[]);var e=gform.hooks[o][n];null==i&&(i=n+\"_\"+e.length),gform.hooks[o][n].push({tag:i,callable:r,priority:t=null==t?10:t})},doHook:function(n,o,r){var t;if(r=Array.prototype.slice.call(r,1),null!=gform.hooks[n][o]&&((o=gform.hooks[n][o]).sort(function(o,n){return o.priority-n.priority}),o.forEach(function(o){\"function\"!=typeof(t=o.callable)&&(t=window[t]),\"action\"==n?t.apply(null,r):r[0]=t.apply(null,r)})),\"filter\"==n)return r[0]},removeHook:function(o,n,t,i){var r;null!=gform.hooks[o][n]&&(r=(r=gform.hooks[o][n]).filter(function(o,n,r){return!!(null!=i&&i!=o.tag||null!=t&&t!=o.priority)}),gform.hooks[o][n]=r)}});<\/script>\n                <div class='gf_browser_gecko gform_wrapper gform_legacy_markup_wrapper gform-theme--no-framework' data-form-theme='legacy' data-form-index='0' id='gform_wrapper_16' style='display:none'>\n                        <div class='gform_heading'>\n                            <h3 class=\"gform_title\">SHS Feedback Form<\/h3>\n                            <p class='gform_description'><\/p>\n                        <\/div><form method='post' enctype='multipart\/form-data'  id='gform_16'  action='\/shs\/wp-json\/wp\/v2\/pages\/2563' data-formid='16' >\n                        <div class='gform-body gform_body'><ul id='gform_fields_16' class='gform_fields top_label form_sublabel_below description_below'><li id=\"field_16_1\"  class=\"gfield gfield--type-radio gfield--type-choice gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_16_1\"><label class='gfield_label gform-field-label'  >I am a:<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_16_1'>\n\t\t\t<li class='gchoice gchoice_16_1_0'>\n\t\t\t\t<input name='input_1' type='radio' value='Student'  id='choice_16_1_0'    \/>\n\t\t\t\t<label for='choice_16_1_0' id='label_16_1_0' class='gform-field-label gform-field-label--type-inline'>Student<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_16_1_1'>\n\t\t\t\t<input name='input_1' type='radio' value='Parent or guardian'  id='choice_16_1_1'    \/>\n\t\t\t\t<label for='choice_16_1_1' id='label_16_1_1' class='gform-field-label gform-field-label--type-inline'>Parent or guardian<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_16_1_2'>\n\t\t\t\t<input name='input_1' type='radio' value='BU faculty or staff'  id='choice_16_1_2'    \/>\n\t\t\t\t<label for='choice_16_1_2' id='label_16_1_2' class='gform-field-label gform-field-label--type-inline'>BU faculty or staff<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_16_1_3'>\n\t\t\t\t<input name='input_1' type='radio' value='gf_other_choice'  id='choice_16_1_3'   onfocus=\"jQuery(this).next('input').focus();\" \/>\n\t\t\t\t<input class='small' id='input_16_1_other' name='input_1_other' type='text' value='Other' aria-label='Other' onfocus='jQuery(this).prev(\"input\")[0].click(); if(jQuery(this).val() == \"Other\") { jQuery(this).val(\"\"); }' onblur='if(jQuery(this).val().replace(\" \", \"\") == \"\") { jQuery(this).val(\"Other\"); }'   \/>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_16_2\"  class=\"gfield gfield--type-select gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_16_2\"><label class='gfield_label gform-field-label' for='input_16_2' >Please choose the department you visited or interacted with:<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_select'><select name='input_2' id='input_16_2' class='medium gfield_select'    aria-required=\"true\" aria-invalid=\"false\" ><option value='Primary Care' >Primary Care<\/option><option value='Primary Care - Lab' >Primary Care &#8211; Lab<\/option><option value='Primary Care - COVID-19 Issue' >Primary Care &#8211; COVID-19 Issue<\/option><option value='Immunization Clinic' >Immunization Clinic<\/option><option value='Counseling &amp; Psychiatric Services (CAPS)' >Counseling &amp; Psychiatric Services (CAPS)<\/option><option value='Health Promotion &amp; Prevention' >Health Promotion &amp; Prevention<\/option><option value='SARP' >SARP<\/option><option value='Athletic Training' >Athletic Training<\/option><option value='Patient Services (front desk)' >Patient Services (front desk)<\/option><option value='Student Health Insurance Plan' >Student Health Insurance Plan<\/option><option value='Patient Connect website' >Patient Connect website<\/option><\/select><\/div><\/li><li id=\"field_16_33\"  class=\"gfield gfield--type-date gfield--input-type-datepicker gfield--datepicker-no-icon field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_16_33\"><label class='gfield_label gform-field-label' for='input_16_33' >Date of experience (if applicable)<\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_33' id='input_16_33' type='text' value='' class='datepicker gform-datepicker mdy datepicker_no_icon gdatepicker-no-icon'   placeholder='mm\/dd\/yyyy' aria-describedby=\"input_16_33_date_format\" aria-invalid=\"false\" \/>\n                            <span id='input_16_33_date_format' class='screen-reader-text'>MM slash DD slash YYYY<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_16_33' class='gform_hidden' value='https:\/\/www.bu.edu\/shs\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/li><li id=\"field_16_3\"  class=\"gfield gfield--type-radio gfield--type-choice field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_16_3\"><label class='gfield_label gform-field-label'  >I would like to report a:<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_16_3'>\n\t\t\t<li class='gchoice gchoice_16_3_0'>\n\t\t\t\t<input name='input_3' type='radio' value='Positive experience'  id='choice_16_3_0'    \/>\n\t\t\t\t<label for='choice_16_3_0' id='label_16_3_0' class='gform-field-label gform-field-label--type-inline'>Positive experience<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_16_3_1'>\n\t\t\t\t<input name='input_3' type='radio' value='Negative experience'  id='choice_16_3_1'    \/>\n\t\t\t\t<label for='choice_16_3_1' id='label_16_3_1' class='gform-field-label gform-field-label--type-inline'>Negative experience<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_16_3_2'>\n\t\t\t\t<input name='input_3' type='radio' value='Suggestion for improvement or idea'  id='choice_16_3_2'    \/>\n\t\t\t\t<label for='choice_16_3_2' id='label_16_3_2' class='gform-field-label gform-field-label--type-inline'>Suggestion for improvement or idea<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_16_4\"  class=\"gfield gfield--type-textarea gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_16_4\"><label class='gfield_label gform-field-label' for='input_16_4' >Tell us what went well?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_4' id='input_16_4' class='textarea medium'     aria-required=\"true\" aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/li><li id=\"field_16_5\"  class=\"gfield gfield--type-textarea gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_16_5\"><label class='gfield_label gform-field-label' for='input_16_5' >Please share your suggestions for improvement or ideas.<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_5' id='input_16_5' class='textarea medium'     aria-required=\"true\" aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/li><li id=\"field_16_10\"  class=\"gfield gfield--type-section gsection field_sublabel_below gfield--has-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_16_10\"><h2 class=\"gsection_title\">Please describe the problem<\/h2><div class='gsection_description' id='gfield_description_16_10'>How would you describe the nature of the problem you experienced? Please check all that apply. <\/div><\/li><li id=\"field_16_8\"  class=\"gfield gfield--type-checkbox gfield--type-choice field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_16_8\"><label class='gfield_label gform-field-label gfield_label_before_complex'  >Access to Care<\/label><div class='ginput_container ginput_container_checkbox'><ul class='gfield_checkbox' id='input_16_8'><li class='gchoice gchoice_16_8_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_8.1' type='checkbox'  value='Long wait time'  id='choice_16_8_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_16_8_1' id='label_16_8_1' class='gform-field-label gform-field-label--type-inline'>Long wait time<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_16_8_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_8.2' type='checkbox'  value='Unable to obtain services from a specific provider'  id='choice_16_8_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_16_8_2' id='label_16_8_2' class='gform-field-label gform-field-label--type-inline'>Unable to obtain services from a specific provider<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_16_8_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_8.3' type='checkbox'  value='Unable to obtain a specific type of treatment'  id='choice_16_8_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_16_8_3' id='label_16_8_3' class='gform-field-label gform-field-label--type-inline'>Unable to obtain a specific type of treatment<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_16_8_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_8.4' type='checkbox'  value='Request for service denied by provider'  id='choice_16_8_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_16_8_4' id='label_16_8_4' class='gform-field-label gform-field-label--type-inline'>Request for service denied by provider<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_16_8_5'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_8.5' type='checkbox'  value='Location not physically accessible or welcoming (e.g. not enough chairs or parking)'  id='choice_16_8_5'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_16_8_5' id='label_16_8_5' class='gform-field-label gform-field-label--type-inline'>Location not physically accessible or welcoming (e.g. not enough chairs or parking)<\/label>\n\t\t\t\t\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_16_9\"  class=\"gfield gfield--type-checkbox gfield--type-choice field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_16_9\"><label class='gfield_label gform-field-label gfield_label_before_complex'  >Customer Service\/Attitude<\/label><div class='ginput_container ginput_container_checkbox'><ul class='gfield_checkbox' id='input_16_9'><li class='gchoice gchoice_16_9_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_9.1' type='checkbox'  value='Provider does not return calls or messages'  id='choice_16_9_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_16_9_1' id='label_16_9_1' class='gform-field-label gform-field-label--type-inline'>Provider does not return calls or messages<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_16_9_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_9.2' type='checkbox'  value='Rude treatment or lack of courtesy by health care provider or staff'  id='choice_16_9_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_16_9_2' id='label_16_9_2' class='gform-field-label gform-field-label--type-inline'>Rude treatment or lack of courtesy by health care provider or staff<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_16_9_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_9.3' type='checkbox'  value='Incorrect information provided'  id='choice_16_9_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_16_9_3' id='label_16_9_3' class='gform-field-label gform-field-label--type-inline'>Incorrect information provided<\/label>\n\t\t\t\t\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_16_11\"  class=\"gfield gfield--type-checkbox gfield--type-choice field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_16_11\"><label class='gfield_label gform-field-label gfield_label_before_complex'  >Cultural Sensitivity<\/label><div class='ginput_container ginput_container_checkbox'><ul class='gfield_checkbox' id='input_16_11'><li class='gchoice gchoice_16_11_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_11.1' type='checkbox'  value='Insensitivity to cultural\/language needs'  id='choice_16_11_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_16_11_1' id='label_16_11_1' class='gform-field-label gform-field-label--type-inline'>Insensitivity to cultural\/language needs<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_16_11_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_11.2' type='checkbox'  value='Lack of diversity among providers or staff'  id='choice_16_11_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_16_11_2' id='label_16_11_2' class='gform-field-label gform-field-label--type-inline'>Lack of diversity among providers or staff<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_16_11_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_11.3' type='checkbox'  value='Lack of providers who speak diverse languages'  id='choice_16_11_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_16_11_3' id='label_16_11_3' class='gform-field-label gform-field-label--type-inline'>Lack of providers who speak diverse languages<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_16_11_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_11.4' type='checkbox'  value='Unable to obtain translation service'  id='choice_16_11_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_16_11_4' id='label_16_11_4' class='gform-field-label gform-field-label--type-inline'>Unable to obtain translation service<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_16_11_5'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_11.5' type='checkbox'  value='Provider did not use my correct pronouns or preferred name'  id='choice_16_11_5'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_16_11_5' id='label_16_11_5' class='gform-field-label gform-field-label--type-inline'>Provider did not use my correct pronouns or preferred name<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_16_11_6'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_11.6' type='checkbox'  value='Gender affirming healthcare concern'  id='choice_16_11_6'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_16_11_6' id='label_16_11_6' class='gform-field-label gform-field-label--type-inline'>Gender affirming healthcare concern<\/label>\n\t\t\t\t\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_16_12\"  class=\"gfield gfield--type-checkbox gfield--type-choice field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_16_12\"><label class='gfield_label gform-field-label gfield_label_before_complex'  >Billing Issues<\/label><div class='ginput_container ginput_container_checkbox'><ul class='gfield_checkbox' id='input_16_12'><li class='gchoice gchoice_16_12_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_12.1' type='checkbox'  value='I was billed more than I anticipated'  id='choice_16_12_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_16_12_1' id='label_16_12_1' class='gform-field-label gform-field-label--type-inline'>I was billed more than I anticipated<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_16_12_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_12.2' type='checkbox'  value='Problem with Aetna Student Health Insurance Plan'  id='choice_16_12_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_16_12_2' id='label_16_12_2' class='gform-field-label gform-field-label--type-inline'>Problem with Aetna Student Health Insurance Plan<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_16_12_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_12.3' type='checkbox'  value='Other insurance issue (non SHIP plan)'  id='choice_16_12_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_16_12_3' id='label_16_12_3' class='gform-field-label gform-field-label--type-inline'>Other insurance issue (non SHIP plan)<\/label>\n\t\t\t\t\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_16_13\"  class=\"gfield gfield--type-checkbox gfield--type-choice field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_16_13\"><label class='gfield_label gform-field-label gfield_label_before_complex'  >Healthcare Quality<\/label><div class='ginput_container ginput_container_checkbox'><ul class='gfield_checkbox' id='input_16_13'><li class='gchoice gchoice_16_13_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_13.1' type='checkbox'  value='Dissatisfaction with treatment plan or outcome'  id='choice_16_13_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_16_13_1' id='label_16_13_1' class='gform-field-label gform-field-label--type-inline'>Dissatisfaction with treatment plan or outcome<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_16_13_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_13.2' type='checkbox'  value='Improper testing or test results not given'  id='choice_16_13_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_16_13_2' id='label_16_13_2' class='gform-field-label gform-field-label--type-inline'>Improper testing or test results not given<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_16_13_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_13.3' type='checkbox'  value='Medication error'  id='choice_16_13_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_16_13_3' id='label_16_13_3' class='gform-field-label gform-field-label--type-inline'>Medication error<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_16_13_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_13.4' type='checkbox'  value='Misdiagnosis'  id='choice_16_13_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_16_13_4' id='label_16_13_4' class='gform-field-label gform-field-label--type-inline'>Misdiagnosis<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_16_13_5'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_13.5' type='checkbox'  value='Provider said something that made me feel uncomfortable'  id='choice_16_13_5'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_16_13_5' id='label_16_13_5' class='gform-field-label gform-field-label--type-inline'>Provider said something that made me feel uncomfortable<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_16_13_6'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_13.6' type='checkbox'  value='Provider touched me in a way that made me feel uncomfortable'  id='choice_16_13_6'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_16_13_6' id='label_16_13_6' class='gform-field-label gform-field-label--type-inline'>Provider touched me in a way that made me feel uncomfortable<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_16_13_7'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_13.7' type='checkbox'  value='Breach of privacy or confidentiality'  id='choice_16_13_7'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_16_13_7' id='label_16_13_7' class='gform-field-label gform-field-label--type-inline'>Breach of privacy or confidentiality<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_16_13_8'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_13.8' type='checkbox'  value='Dissatisfaction with protocol or process'  id='choice_16_13_8'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_16_13_8' id='label_16_13_8' class='gform-field-label gform-field-label--type-inline'>Dissatisfaction with protocol or process<\/label>\n\t\t\t\t\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_16_14\"  class=\"gfield gfield--type-checkbox gfield--type-choice field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_16_14\"><label class='gfield_label gform-field-label gfield_label_before_complex'  >Website\/Patient Connect<\/label><div class='ginput_container ginput_container_checkbox'><ul class='gfield_checkbox' id='input_16_14'><li class='gchoice gchoice_16_14_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_14.1' type='checkbox'  value='Student website\/portal issue'  id='choice_16_14_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_16_14_1' id='label_16_14_1' class='gform-field-label gform-field-label--type-inline'>Student website\/portal issue<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_16_14_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_14.2' type='checkbox'  value='Incorrect information on website'  id='choice_16_14_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_16_14_2' id='label_16_14_2' class='gform-field-label gform-field-label--type-inline'>Incorrect information on website<\/label>\n\t\t\t\t\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_16_15\"  class=\"gfield gfield--type-textarea field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_16_15\"><label class='gfield_label gform-field-label' for='input_16_15' >Other &#8211; Please Describe<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_15' id='input_16_15' class='textarea small'      aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/li><li id=\"field_16_16\"  class=\"gfield gfield--type-textarea field_sublabel_below gfield--has-description field_description_above gfield_visibility_visible\"  data-js-reload=\"field_16_16\"><label class='gfield_label gform-field-label' for='input_16_16' >Please tell us more?<\/label><div class='gfield_description' id='gfield_description_16_16'>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?<\/div><div class='ginput_container ginput_container_textarea'><textarea name='input_16' id='input_16_16' class='textarea medium'  aria-describedby=\"gfield_description_16_16\"    aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/li><li id=\"field_16_17\"  class=\"gfield gfield--type-radio gfield--type-choice field_sublabel_below gfield--has-description field_description_above gfield_visibility_visible\"  data-js-reload=\"field_16_17\"><label class='gfield_label gform-field-label'  >Would you like to change providers?<\/label><div class='gfield_description' id='gfield_description_16_17'>If yes, please consider selecting &#8220;yes&#8221; 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. <\/div><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_16_17'>\n\t\t\t<li class='gchoice gchoice_16_17_0'>\n\t\t\t\t<input name='input_17' type='radio' value='Yes'  id='choice_16_17_0'    \/>\n\t\t\t\t<label for='choice_16_17_0' id='label_16_17_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_16_17_1'>\n\t\t\t\t<input name='input_17' type='radio' value='No'  id='choice_16_17_1'    \/>\n\t\t\t\t<label for='choice_16_17_1' id='label_16_17_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_16_17_2'>\n\t\t\t\t<input name='input_17' type='radio' value='N\/A'  id='choice_16_17_2'    \/>\n\t\t\t\t<label for='choice_16_17_2' id='label_16_17_2' class='gform-field-label gform-field-label--type-inline'>N\/A<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_16_31\"  class=\"gfield gfield--type-section gsection field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_16_31\"><h2 class=\"gsection_title\"><\/h2><\/li><li id=\"field_16_18\"  class=\"gfield gfield--type-radio gfield--type-choice field_sublabel_below gfield--has-description field_description_above gfield_visibility_visible\"  data-js-reload=\"field_16_18\"><label class='gfield_label gform-field-label'  >Would you like to be contacted for follow-up?<\/label><div class='gfield_description' id='gfield_description_16_18'>If yes, please provide your preferred contact method. To remain anonymous, choose no. <\/div><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_16_18'>\n\t\t\t<li class='gchoice gchoice_16_18_0'>\n\t\t\t\t<input name='input_18' type='radio' value='Yes'  id='choice_16_18_0'    \/>\n\t\t\t\t<label for='choice_16_18_0' id='label_16_18_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_16_18_1'>\n\t\t\t\t<input name='input_18' type='radio' value='No'  id='choice_16_18_1'    \/>\n\t\t\t\t<label for='choice_16_18_1' id='label_16_18_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_16_19\"  class=\"gfield gfield--type-name gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_16_19\"><label class='gfield_label gform-field-label gfield_label_before_complex'  >Name<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_complex ginput_container ginput_container--name no_prefix has_first_name no_middle_name has_last_name no_suffix gf_name_has_2 ginput_container_name gform-grid-row' id='input_16_19'>\n                            \n                            <span id='input_16_19_3_container' class='name_first gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_19.3' id='input_16_19_3' value=''   aria-required='true'     \/>\n                                                    <label for='input_16_19_3' class='gform-field-label gform-field-label--type-sub '>First<\/label>\n                                                <\/span>\n                            \n                            <span id='input_16_19_6_container' class='name_last gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_19.6' id='input_16_19_6' value=''   aria-required='true'     \/>\n                                                    <label for='input_16_19_6' class='gform-field-label gform-field-label--type-sub '>Last<\/label>\n                                                <\/span>\n                            \n                        <\/div><\/li><li id=\"field_16_30\"  class=\"gfield gfield--type-text gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_16_30\"><label class='gfield_label gform-field-label' for='input_16_30' >BU ID Number<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_30' id='input_16_30' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_16_22\"  class=\"gfield gfield--type-radio gfield--type-choice field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_16_22\"><label class='gfield_label gform-field-label'  >Preferred Contact Method<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_16_22'>\n\t\t\t<li class='gchoice gchoice_16_22_0'>\n\t\t\t\t<input name='input_22' type='radio' value='Email'  id='choice_16_22_0'    \/>\n\t\t\t\t<label for='choice_16_22_0' id='label_16_22_0' class='gform-field-label gform-field-label--type-inline'>Email<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_16_22_1'>\n\t\t\t\t<input name='input_22' type='radio' value='Phone'  id='choice_16_22_1'    \/>\n\t\t\t\t<label for='choice_16_22_1' id='label_16_22_1' class='gform-field-label gform-field-label--type-inline'>Phone<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_16_20\"  class=\"gfield gfield--type-email field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_16_20\"><label class='gfield_label gform-field-label' for='input_16_20' >Email<\/label><div class='ginput_container ginput_container_email'>\n                            <input name='input_20' id='input_16_20' type='text' value='' class='medium'     aria-invalid=\"false\"  \/>\n                        <\/div><\/li><li id=\"field_16_21\"  class=\"gfield gfield--type-phone field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_16_21\"><label class='gfield_label gform-field-label' for='input_16_21' >Phone<\/label><div class='ginput_container ginput_container_phone'><input name='input_21' id='input_16_21' type='text' value='' class='medium'    aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_16_28\"  class=\"gfield gfield--type-section gsection field_sublabel_below 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