This tool appears in the Health Care Compliance Association’s The Complete Compliance and Ethics Manual 2023.[1]
Compliance Issue Report Intake Form
Date/time of initial report:
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Name of person completing the intake form:
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Name of person reporting a potential issue (if provided):
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Callback number or contact email for reporter (if provided):
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Department in which reporter works:
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Description of question or concern:
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Has this issue been previously reported, and if so, to whom?
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Potential issue types involved (circle primary issue type and check secondary issue types:
☐ Bribery
☐ Kickbacks
☐ Accounting
☐ Harassment
☐ Discrimination
☐ Product safety
☐ Health & Safety
☐ Environmental
☐ Financial controls
☐ Retaliation
☐ Conflict of interest
☐ Employee relations
☐ Fair competition
☐ Human trafficking/Forced labor
☐ Trade compliance
☐ Data privacy
☐ Misuse of company resources
☐ Intellectual property
Name(s) of other person(s) with potential knowledge of the issue:
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Name of the person to whom this is assigned for investigation:
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Date matter assigned to investigator:
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Investigation plan:
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Follow-up date:
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Follow-up actions:
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Final disposition of the issue:
☐ Substantiated
☐ Unsubstantiated
☐ Insufficient Information
Disciplinary action taken?
☐ Yes
☐ No
Summary of findings, issue resolution, mitigating actions, and next steps:
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Issue closure date:
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Time to close:
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Signature of investigator:
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