Initial Complaint Form

Type of Complaint:*

Please note: The Company may still determine in its discretion that a formal complaint and investigation is required.

I am completing this report on behalf of:*

ClientCaregiverMyselfOther

Do you wish to remain anonymous for this report?*

YesNo

Name of person filing complaint: (This should be the name of the person who called the office to file a complaint NOT the name of the office completing this form)*

Select the name of the company this report is regarding:*

Select the general topic the complaint falls under:

Enter Complaint Topic:*

Who is the complaint about and what is their relationship to the victim?*

Was management aware of this problem prior to your filing this complaint?*

YesNoI do not knowDo not wish to disclose

If yes, who has been made aware? Please elaborate.

Any persons mentioned here will be restricted from access to this reported information.

Please provide all details regarding the incident, including the locations of witnesses and any other information that could be valuable in the evaluation and ultimate resolution of this situation:*

Where did this incident or violation occur?*

We recognize that this incident may not have occurred in a particular location. Please indicate if the incident was observed in some documentation or business transactions.

Please provide the specific or approximate date and time this incident occurred?*

How long do you think this problem has been going on?*

Please identify the name and title of any persons who have attempted to conceal this problem and the steps they took to conceal it. Identify if you believe that management was involved. (If not applicable write N/A):*

Examples: Ignored it, changed documents, said it was not a problem, said they would look into it

Upload any document or file you have that supports your report:

Honor Health Network and its affiliated companies

Terms and Conditions

REPORTER PRIVACY
Honor Health Network treats reports received as confidential and shares any report received in accordance with Privacy Statement. Honor Health Network only uses the information submitted by reporters to provide services to its Customers and in accordance with Honor Health Network's Privacy Statement. By submitting a report, you authorize the organization about which you are filing a report, and its affiliated and subsidiary companies, to collect, process, store and otherwise use the report and information submitted as that organization deems appropriate.
In addition to the disclosures identified elsewhere in these Terms and Conditions, Honor Health Network may disclose information about you as required by law, to protect and secure the integrity of our systems and data we host, and may be shared with law enforcement to enforce our rights or as otherwise required by applicable law.

DISCLAIMER
Honor Health Network does not warrant the accuracy or reliability of the information collected, nor does it investigate or resolve issues or concerns submitted. Please be advised that Honor Health Network's Customer is responsible for evaluating the information submitted and complying with all applicable local, state or federal laws, rules or regulations relating to the investigation and protection of the information submitted. Honor Health Network's system is not a government classified system. You are specifically prohibited from uploading any information which may be considered Top Secret, Secret and/or confidential information that requires safeguarding in the interest of national security.

RELEASE
By submitting a report to Honor Health Network, you understand and acknowledge that Honor Health Network's sole obligation is to receive your report. Honor Health Network will incur no liability as a result of the action or inaction of its Customer. You, on behalf of yourself and your heirs, successors, family members, agents and assigns, agree to and do hereby release Honor Health Network and its respective officers, directors, shareholders, employees, successors, predecessors, agents and assigns, of and from any and all liability, claims, actions, causes of action and damages which relate in any way to Honor Health Network's Customer's actions or failure to act as the result of having received, or having access to, information related to a report.

SEVERABILITY
If any provision of these Terms and Conditions conflicts with governing law or if any provision is held to be null, void, or otherwise ineffective or invalid by a court of competent jurisdiction the remaining terms, provisions, covenants, and restrictions of these Terms and Conditions shall remain in full force and effect.

ACKNOWLEDGEMENT
Honor Health Network take the reports made through this site seriously. Do not intentionally include false or misleading information in your report. The intentional reporting of false or misleading information can result in civil or criminal liability. The Parties agree that the Uniform Computer Information Transactions Act (UCITA) shall not apply to these Terms and Conditions.

Please read the Terms & Conditions above, then check off the box below to agree.*

I agree to the Terms & Conditions, listed above, of making this report.

Name of Person Completing this Form*

Title of Person Completing this Form*

Signature of person completing this Form*

Date*

Please complete the following:*

Please identify the person(s) engaged in this behavior:*

Please provide all details regarding the alleged violation, including the locations of witnesses and any other information that could be valuable in the evaluation and ultimate resolution of this situation:*

Please take your time and provide as much detail as possible, but exercise care to not provide details that may reveal your identity unless you wish to do so. It may be important to know if you are the only person aware of this situation.

How did you become aware of this violation?*

If other, how?

Do you want to file this as a formal complaint?*

YesNo