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 former as well as current 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. Name:Do not provide this information if you wish to remain anonymous. Phone Number:Do not provide this information if you wish to remain anonymous.Department:(Required) Details:(Required)Please describe what happened with as much detail as possible. Date:(Required)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? Yes No Outcome:(Required)If so, on what date and what was the outcome?Was patient care affected?(Required) Yes No Solution:What would you consider to be a proper solution to this issue?NameThis field is for validation purposes and should be left unchanged. Δ
