|
Confidential AND
Privileged Information
Materials included herein must be
maintained by the
Compliance Committee as confidential and
filed in a manner which will not result
in the release of
such
information to third parties or other employees who are not considered
necessary to the subject matter.
|
|
Methodist Home for Nursing and
Rehabilitation
Compliance Complaint/Violation/Suggestion Report Form |
| 1. Complainant Information: |
2. Anonymous Complaints: |
|
Name:
Date:
Address:
City:
State:
Zip:
Email:
Telephone:
|
If
you are an Employee, Vendor
or Agent and wish to remain anonymous, please detail your complaint or
allegation of violation below without including the identifying
information
requested in the Complainant Information Box. Please
be aware that the failure to
provide specific information may impede the full and complete
investigation of
this matter. |
|
| To
ensure employee cooperation, the Methodist Home will not take any
retaliatory
action or retribution against any employee who has submitted a report
of a
suspected violation or who has participated in an investigation of a
suspected
violation in good faith. Any
employee
who takes retaliatory action or retribution against another employee
who has
either reported a suspected violation or participated in an
investigation of a
suspected violation will be subject to disciplinary action. |
|
| 3. Summary
of Complaint/Violation or Suggestion: |
|
|
|
| 4. Additional
Detail (Provide names, dates, location and/or other specifics
regarding the
complaint, allegation or suggestion) |
|
| 5. Alternative Contact
Information ->: |
|
|
|
| Print, sign and mail this form
to: |
To submit electronically: |
Methodist Home for
Nursing
and Rehabilitation
Corporate Compliance Officer
4499 Manhattan College Parkway
Bronx, New York 10471-3998 |
|