Exhibit S_RHRP Customer Concern Form (2025).docx
DOCX document 44 KB Posted
- Attached to
- Remote Health Readiness Program 4 (RHRP-4)
- Solicitation number
- HT001125R0020
- Issued by
-
Defense Health Agency
About this file
The document is a Customer Concern Form for the Remote Health Readiness Program (RHRP), designed to document and track customer issues, complaints, and service concerns related to medical and dental readiness services. The form provides a structured five-section process for reporting, investigating, and resolving customer concerns, with specific timelines and evaluation criteria for different types of concerns.
The form categorizes concerns into two primary classifications: Non-Validated Concerns (minor issues requiring response within 15 calendar days) and Validated Concerns (significant issues directly impacting deployment, promotion, or training, requiring investigation and action plan within 30 calendar days). The process involves multiple stakeholders including the customer, RHRP Liaison Officer, government reviewers, Service Component Program Manager, and RHRP Program Management Office, ensuring comprehensive tracking and resolution of reported issues through a systematic, multi-step review and response mechanism.
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Text version
Remote 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 Remote 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.
Email completed form to RHRP Program Management Office: DHA.RHRP@health.mil Section 1. Customer Information Please Complete Customer Information
| Service Component/Unit Information: |
| Date of Report: |
Full Name/Rank/Title:
| Email: |
| 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: |
Service or Procedure Description (e.g. Vision Screen, PHA, Hearing Test)
For Group Event only:
| Group Event Name |
| Group Event ID (if known) |
| Group Event Location (City, State) |
For In-Clinic only:
| Provider Name / ID: |
| Provider Location (City, State) |
Describe Concern:
| Customer Signature: |
| Date: |
Section 2. RHRP Liaison Officer RHRP Liaison Officer to Complete Section 2.
| RHRP Tracking # |
| Customer Tracking # |
| Received Date: |
Full Name / Rank / Title:
Email:
Recommended Action(s):
RHRP Liaison Officer Signature:
Date:
Section 3. Investigation and Corrective Action Upon review by the Government, this concern meets the following operational definition and corresponding corrective action:
| Classification |
| Description |
| Corrective Action |
| Non-Validated Concern |
| 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. |
| Response to customer required within 15 calendar days following receipt of notification |
| Validated Concern |
| Event or process resulted in actions exacerbating the original condition or directly impacted deployment, promotion, training, etc. Government (COR) determined this is a validated concern and requires follow-up. |
| Investigate concern, create action plan, and execute action plan to close out concern within 30 calendar days of receipt of notification by the Government (COR). |
3a. Reviewer Evaluation and Corrective Action Response
Reviewer Full Name / Rank / Title:
Received Date:
| Email: |
| Phone: |
Summary and Conclusion(s):
Results of Investigation: |_| Non-Validated Concern |_| Validated Concern
Corrective Action(s):
Reviewer Signature:
Date:
Section 4. Service Component Response Service Component RHRP Program Manager to Complete Section 4.
Full Name / Rank / Title:
Email:
Investigation Results:
|_| Accept |_| Reject Corrective Actions:
|_| Satisfactory |_| Unsatisfactory
Comments:
SC RHRP Program Manager Signature:
Date:
Section 5. PMO, RHRP Response and Close-Out Director or Deputy Director RHRP to close-out response
Full Name / Rank / Title:
Email:
Investigation Results:
|_| Accept |_| Reject Corrective Actions:
|_| Satisfactory |_| Unsatisfactory
Comments:
PMO, RHRP Signature:
Date:
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