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CONFIDENTIAL / Attachment A / Policy# 15
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Corporate Compliance Office Compliance In-take Form |
Concern originates from: □ ABC Health System □ 123 Health System |
Reporting Method used: □ Letter (attached ) □ In person (drop in) □ Phone Call □ Fax | |||
| Date reported: | Time: | Received by: | |||
| Name of Person Reporting Concern: | |||||
| Person’s Title: | |||||
| □ Does not wish to give name | □ Requests identity to be kept in confidence | ||||
| Contact Phone Number: | home: | work: | |||
| Nature of Call: | □ Complaint | □ Request for Guidance | □ Informational | ||
| Site/Location of Concern: | |||||
| Relevant Information About Allegation: | |||||
| Was this concern reported to Compliance Office previously? (If yes, review existing file) | □ Yes | □ No | □ Not sure | ||
| Initial Advice or Information given to person when reporting the concern: | |||||
| Does investigation need to be done by another department? | □ Yes | □ No | |||
| If yes, department contact: | date routed: | ||||
| Was the concern resolved? | □ Yes | □ No | □ Not sure (Concern forwarded to other department for resolution) | ||
| □ Concern entered into CompTrack / paperwork filed | |||||
| □ Concern routed to: | for entry in CompTrack | ||||