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Fill out our electronic form to file a report with our Compliance Officer.

  • Type of report
  • Who or what prompted this report
  • Name of employee or hospital associate involved in this event or action.
  • Summarize the event you are reporting. There is an opportunity to upload additional documentation at end of this form.
  • Enter the date the event occurred
    Date Format: MM slash DD slash YYYY
  • Enter approximate time of incident or encounter.
    :
  • Choose the category that best fits the circumstances of this event or incident:
  • Choose the department your report is associated with.
  • Of Person Filing Report
  • Required only for communication regarding this report. Will only be used by the Compliance Committee for purposes of obtaining more information or reporting action taken.
  • To provide additional documentation on this report.
    Drop files here or
    Accepted file types: pdf, png, gif, jpg, txt.
  • This field is for validation purposes and should be left unchanged.
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