Form

Tell Us About Your Health Care Experience
Thank you for telling us about your health care experience. Please know, all questions are optional. Our goal is to support all individuals.

Client's Name

Anonymous

Email*

Do you think the health care experience was influenced by how the individual identifies, or, by race/ethicity?

Yes

Don't know

Explain: Medical

Was the health care experience good or bad?

good

bad

If the health care experience was good, please describe below:

When did the concern begin?

Please estimate if you do not recall an exact date

Month/Day/Year

If the health care experience was good, what if anything could have been done to make it even better?

Location of the health care provider/facility/other organization involved -City

Location of health care provider/facility/other organization involved - State

If the health care experience was bad, please describe it below:

If the health care experience was bad, what could have been done to make it better?

Do you think the health care experience was personal or systemic (happens to everyone)?

Personal

Systemic

Not sure

Was physical harm caused by the health care experience?

Yes

If yes, describe the physical harm:

Was physical harm prevented or avoided?

Yes

If yes, describe how it was prevented or avoided:

Was emotional harm caused by the health care experience?

Yes

If yes, describe the emotional harm:

Was emotional harm prevented or avoided?

Yes

If yes, describe how the emotional harm was prevented or avoided:

Message

Thank you for sharing your experiences. If we share this information, be assured, it will be in unidentified form; this will only be used to improve the experiences of all patients and to empower individuals to advocate for themselves.

JKPPA will not directly reach out to health care providers to obtain protected health care information. By providing private information or access to private information to JKPPA and its partner volunteers you understand that we intend to use the information to assist you and to promote the mission of JKPPA. Although JKPPA is not a covered entity for HIPAA purposes, we use our best efforts to maintain the privacy of health information and do not voluntarily make disclosures to others. JKPPA is here to support you!

If you need assistance navigating your health care, please complete our Request Help Form or email or call us at Navigator@JKPPA.org or 215-886-HELP (4357).