Ostomy and Continent Diversion
Patient Bill of Rights
Feedback Form

Help us ensure our self-advocacy tool is effective.

Let us know about your experience using

the patient bill of rights.

Thank you for helping us work towards

a gold standard of care and drive change.

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* 1. Contact Information (Your information will not be shared.)

Name (First, Last) *

Address

Address 2

City/Town

State *

ZIP/Postal Code *

Email Address *

Phone Number

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* 2. When did you have your ostomy or continent diversion surgery?

Date

Date

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* 3. When did you use our patient bill of rights?

Date

Date

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* 4. How did you obtain our patient bill of rights?

Other (please specify)

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* 5. Where did you use our patient bill of rights? (type of facility, location)

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* 6. What was your story? (Problem? Outcome? Would you do it differently next time?)

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* 7. Who did you share the patient bill of rights with to improve quality of care?

Or other (please specify)

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* 8. Do you think the situation was improved?

Yes

No

I don't know

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* 9. How did you use the patient bill of rights?

To make a complaint about quality of care received

To promote change to improve quality of care

Other (please specify)

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* 10. Were the patient bill of rights useful?

Yes

No

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* 11. Would you share these patient bill of rights with someone else?

Yes

No