SERVICE RECOVERY IDENTIFICATION FORM

Today’s date_____/____/_____ Your Name: _____________________________________

Your Department______________ Name of Person Receiving Token____________________

Patient’s Name___________________________ Account #____________________________

Explain service failure and reason for issuing service recovery token:

____________________________________________________________________________

____________________________________________________________________________
____________________________________________________________________________

Specify on the line beside each token how many were issued. (Only 1 auxiliary certificate per person.)

___Titus Bucks ($1.00 each-specify how many) ____$5-“It’s on Us” _____$10 Aux. Gift Cert.

Make a copy of this form after completing. Place copy in your director’s box to be forwarded
to Director of Clinical Excellence, Kandice Pryor.

SERVICE RECOVERY IDENTIFICATION FORM

Today’s date_____/____/_____ Your Name: _____________________________________

Your Department______________ Name of Person Receiving Token____________________

Patient’s Name___________________________ Account #____________________________

Explain service failure and reason for issuing service recovery token:

____________________________________________________________________________

____________________________________________________________________________
____________________________________________________________________________

Specify on the line beside each token how many were issued. (Only 1 auxiliary certificate per person.)

___Titus Bucks ($1.00 each-specify how many) ____$5-“It’s on Us” _____$10 Aux. Gift Cert.

Make a copy of this form after completing. Place copy in your director’s box to be forwarded
to Director of Clinical Excellence, Kandice Pryor.