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Compliance Concern Form
Compliance Concern Submission
On what date did the incident occur?
(Required)
MM slash DD slash YYYY
What time did the incident occur?
(Required)
Hours
:
Minutes
AM
PM
AM/PM
Where did this incident happen?*
(Required)
Name – State the person(s) involved in committing the misconduct:
(Required)
First
Last
Was there more than 1 person involved in committing the violation?
(Required)
Yes
No
Please, state the additional person(s) involved in committing the misconduct:
(Required)
Were there any Witnesses?
(Required)
Yes
No
Witness Name
Is a manager aware of this concern?
(Required)
Yes
No
Manager Name
How did you become aware of the misconduct/incident?
(Required)
Please describe the incident in detail. Take your time and include all factual, pertinent information that you know about the incident.
(Required)
Is this an ANONYMOUS complaint?
(Required)
Yes
No
Anonymous reporters do not provide their name or contact information. If you choose to report anonymously, please be sure that you provide enough information to assist Endwell Family Physicians with conducting an investigation.
Reporter Name
First
Last
Reporter Email
Reporter Phone
Additional Information
Acknowledgment
(Required)
THIS IS NOT A MEDICAL EMERGENCY
I confirm that this is not a medical emergency and that I am not submitting any question regarding my medical care (including communications about appointments, medications, test results, or immunizations).
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