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APPENDIX H | Sample Compliance In-Take Forms

CONFIDENTIAL / Attachment A / Policy# 15

Corporate Compliance Office

Compliance In-take Form

Concern originates from:

ABC Health System

123 Health System

Reporting Method used:

Letter (attached )

E-mail

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
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