RECEPCIN DE QUEJAS,

SUGERENCIAS, RECLAMOS Y
DERECHOS DE PETICIN

Cdigo:
GUF-FO-012

GESTIN AL USUARIO Y SU FAMILIA Versin: 4

Radicacin: ________________
Fecha: _______________________________ Hora: _______________
Nombre y Apellidos: __________________________________________________________________________________
Documento de Identidad: ____________________Correo Electrnico: __________________________________________Seguridad Social_______________
Direccin: ____________________________________________________Telefono:_______________________________
Servicio (marque con una X)
Hospitalizacin ____ Urgencias ____ Consulta Externa ___ Otro ___
Tramite (marque con una x)
Peticin General ___ Peticin Particular ___ Queja ___ Reclamo ___ Solicitud de Informacin ___ Sugerencias ___ Felicitaciones ___
_______________________________________________________________________________________________________________________________
_______________________________________________________________________________________________________________________________
_______________________________________________________________________________________________________________________________
_______________________________________________________________________________________________________________________________
_______________________________________________________________________________________________________________________________
_______________________________________________________________________________________________________________________________
_______________________________________________________________________________________________________________________________
_______________________________________________________________________________________________________________________________
_______________________________________________________________________________________________________________________________
_______________________________________________________________________________________________________________________________
_______________________________________________________________________________________________________________________________
_______________________________________________________________________________________________________________________________
_______________________________________________________________________________________________________________________________
_______________________________________________________________________________________________________________________________
_______________________________________________________________________________________________________________________________
(Si necesita ms espacio, no dude en utilizar el reverso)
Buzn N.

Dependencia

Peticin N.

RECEPCIN DE QUEJAS,
SUGERENCIAS, RECLAMOS Y
DERECHOS DE PETICIN

Cdigo:
GUF-FO-012

GESTIN AL USUARIO Y SU FAMILIA Versin: 4

Radicacin: ________________
Fecha: _______________________________ Hora: _______________
Nombre y Apellidos: __________________________________________________________________________________
Documento de Identidad: ____________________Correo Electrnico: __________________________________________Seguridad Social:______________
Direccin: ____________________________________________________Telefono:_______________________________
Servicio (marque con una X)
Hospitalizacin ____ Urgencias ____ Consulta Externa ___ Otro ___
Tramite (marque con una x)
Peticin General ____ Peticin Particular ___ Queja ___ Reclamo ___ Solicitud Informacin ___ Sugerencia ___ Felicitacin ___
_______________________________________________________________________________________________________________________________
_______________________________________________________________________________________________________________________________
_______________________________________________________________________________________________________________________________
_______________________________________________________________________________________________________________________________
_______________________________________________________________________________________________________________________________
_______________________________________________________________________________________________________________________________
_______________________________________________________________________________________________________________________________
_______________________________________________________________________________________________________________________________
_______________________________________________________________________________________________________________________________
_______________________________________________________________________________________________________________________________
_______________________________________________________________________________________________________________________________
_______________________________________________________________________________________________________________________________
_______________________________________________________________________________________________________________________________
_______________________________________________________________________________________________________________________________
_______________________________________________________________________________________________________________________________
_______________________________________________________________________________________________________________________________
_______________________________________________________________________________________________________________________________
_______________________________________________________________________________________________________________________________
(Si necesita ms espacio, no dude en utilizar el reverso)
Buzn N.

Dependencia

Peticin N.