تاریخ دریافت شکایت : ........................                                       فرم طرح شکایت                                           شماره رسید .........................
دانشگاه علوم پزشکی و خدمات بهداشتی درمانی استان فارس
بیمارستان / شبکه ......................................................................
 
مشخصات شاکی
نام ونام خانوادگی : ............................... کد ملی: ............................... شماره همراه: ............................. تلفن منزل : ..........................
آدرس محل سکونت : ...............................................................................................................................................................................
نام فردی که از طرف شما پیگیر شکایت می باشد : .................................................................. شماره همراه : ....................................
 
مشخصات متشاکی
نام و نام خانوادگی : ..............................................     شماره اتاق : ....................................  مسئولیت : ...............................................
 
                                                                               شرح شکایت                                     پیوست دارد ؟ بلی               خیر
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                                                                                                           امضاء                                                  ادامه در پشت برگ
 
 
 
 
ادامه شرح شکایت:
 
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                                                امضاء :
 
اقدامات صورت گرفته
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                                  امضاء
 
 
 
نتیجه بررسی در تاریخ های ................ ، ............... ، ................. ، ................ به شاکی یا پیگیری کننده شکایت ، اطلاع داده شد.
نظر شاکی : ..............................................................................................................................................................................................
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شکایت مختومه شد                  شکایت به مراجع بالاتر ارجاع داده شد
شماره نامه ارجاع داده شده به مراجع بالاتر ..........................................
شماره نامه تذکر داده شده به متشاکی ..................................................
                                                امضاء متشاکی
 
تاریخ آخرین بروزرسانی   :  1392-2-2 11:14        برو بالای صفحه نسخه قابل چاپ