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320-769-4323   |  Dawson, MN

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Johnson Memorial Health Services

Johnson Memorial Health Services

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Compliance Report Form

JMHS Compliance Report Form

Report will be sent to Compliance Officer.


This report will be kept confidential in accordance with the Compliance Program's procedures and subject to government laws.

Non-retaliation Policy: JMHS policy prohibits retaliation against individuals who report activities that may violate the laws, regulations and facility policies. This includes all employees, contractors and volunteers. Each report is taken seriously and thoroughly reviewed to make sure proper action is taken.

Anonymity Policy: JMHS policy provides for compliance reports to be made anonymously. While giving your name will be helpful if more information is needed, you are not required to include it.

Do not provide this information if you wish to remain anonymous.
Do not provide this information if you wish to remain anonymous.
Please describe what happened with as much detail as possible.
Date of incident or situation.
MM slash DD slash YYYY
Contact:(Required)
Have you contacted the facility or your supervisor to try to resolve the issue?
If so, on what date and what was the outcome?
Was patient care affected?(Required)
What would you consider to be a proper solution to this issue?
This field is for validation purposes and should be left unchanged.

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Clinic Hours

Monday 8:00am-7:00pm
Tuesday 8:00am-5:00pm
Wednesday 8:00am-5:00pm
Thursday 8:00am-5:00pm
Friday 8:00am-5:00pm

Contact Us

1294 Locust Street
Dawson, MN 56232

P: 320-769-4323
F: 320-769-2972

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