Staff Only:Compliance Concern Report

EIHAB Human Services

Compliance Concern Report Form

At Eihab, we hold confidentiality in the highest regard and take all compliance violations with utmost seriousness. Our commitment to maintaining the trust of our stakeholders, employees, and partners is paramount, and any breach of compliance is addressed promptly and thoroughly. In this report, we delve into a recent compliance violation incident, outlining the details, investigation process, and corrective actions taken to ensure adherence to our ethical standards and legal obligations.

Is this an Anonymous Report

Yes

If Yes, Click Here

Date Report Completed

Your First Name

Your Last Name

Your Title/Position

Your Work Location

Your Department/Service

Report Source

Employee

Individual/Family

Independent Contractor

Vendor

Board Member

Other Provider

Other

Has this been previously reported?

Yes

If yes, indicate the report mode:

Supervisor

Supervisor in Command Chain

Compliance Officer

Letter/Note

Hotline

Walk-In/Appointment

Staff Meeting/Training

Other

Report Section

Type of Report

Suspected Violation

Misconduct

Regulatory Violation

Policy Violation

Ethical Business Practice

Is this to report a Compliance Program Violation:

Yes

If no, indicate your report here:

If Yes, Click Here

Compliance Violation

If Yes, Click Here

Please describe in as much detail as possible, the violation: (Please be specific where the violation may have occurred)

When did this occur?

Were you directly involved?

Yes

If so, explain how:

Anyone else directy involved? Is so, please indicate names and position - or any identifying information :

Has this been reported to anyone else within the organization?

Yes

If yes, indicate persons name, title and department

Is there any other documentation or other evidence of alleged violation? If so please upload here:

Add a File

Has this been reported to anyone else outside the organization?

Yes

If yes, indicate persons name, title and department

I hereby declare that all the information provided in this compliance violation report is true to the best of my knowledge and belief. I am aware of the consequences and legal ramifications if any of the claims made in this report are found to be knowingly false.

Your Signature

Today's Date

Full Printe Name

Thanks for submitting!

EIHAB Human Services

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