Exhibit S_RHRP Customer Concern Form (5-2023).pdf

Reserve Health Readiness Program Notification and Response of Customer Concern

Purpose: Document customer issues, concerns, and complaints involving any person, services requested, or services received from Reserve Health Readiness Program (RHRP) and/or the contract partner. The Program Management Office (PMO) and/or contract partner will document the investigation and corrective actions taken to resolve concerns.

Concerns are evaluated on a case-by-case basis. Each submission is entered into a customer concern database for analysis and inclusion in the Quarterly Satisfaction Report

E-Mail completed form to RHRP Service Component Liaison Officer: DHA.RHRP@Health.mil

Section 1. Customer Information Please Complete Customer Information Service Component/ Unit Information: Date of Report:

Full Name / Rank / Title:

E-Mail: Phone:

1a. Describe Nature of Concern Please describe in detail the nature of the concern. Be sure to include supporting documentation, as necessary.

Source of Concern: Date of Occurrence:

Occurrence Type: Describe Other:

Group Event: Group Event ID (if known): Group Event Location (City, State)

In-Clinic: Provider Name / ID: Provider Location (City, State)

Describe Concern:

Customer Signature: Date:

mailto:dha.ncr.healthcare-ops.mbx.rhrp@health.mil?subject=Customer%20Concern%20Report amanda.i.boyd2 Highlight

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Section 2. RHRP Liaison Officer RHRP Liaison Officer to Complete Section 2.

RHRP Tracking #

Customer Tracking #

Received Date:

Full Name / Rank / Title:

E-Mail:

Recommended Action(s):

RHRP Liaison Officer Signature:

Date:

Section 3. Investigation and Corrective Action Upon review by the Customer Resolution Team, this concern is classified as meeting the following operational definition and corresponding corrective action:

Non-Conformity Classification Description Corrective Action

Major Non-Conformance Event or process resulted in actions exacerbating the original condition or directly impacted deployment, promotion, training, etc.

Initiate investigation/evaluation and provide interim containment action plan within 7 working days, completed problem resolution response plan within 30 calendar days following receipt of notification.

Minor Non-Conformance: Event or process inconvenienced Service Member or Service Component resulting in rescheduling of services or other minor problem. No adverse effect on deployment, promotion, training, etc.

Investigation, response plan, and resolution timeframe within 15 calendar days following receipt of notification.

3a. Reviewer Evaluation and Corrective Action Response Reviewer Full Name / Rank / Title:

Date Received:

Phone:

Summary and Conclusion(s):

Results of Investigation: ☐ Major Non-Conformance ☐ Minor Non-Conformance

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Corrective Action(s):

Reviewer Signature: Date:

Section 4. Service Component Response Service Component RHRP Program Manger to Complete Section 4.

Investigation Results: ☐ Accept ☐ Reject Corrective Actions: ☐ Satisfactory ☐ Unsatisfactory Comments:

SC RHRP Program Manager Signature:

Section 5. PMO, RHRP Response and Close-Out Director or Deputy Director RHRP to close-out response

Investigation Results: ☐ Accept ☐ Reject Corrective Actions: ☐ Satisfactory ☐ Unsatisfactory Comments:

PMO, RHRP Signature:

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