Anonymous Compliance and Ethics Reporting Form

Anonymous Compliance and Ethics Reporting Form

At Grace Health, your voice matters.
Purpose of the form:

Grace Health encourages individuals to report privacy and compliance concerns without fear. We provide a secure online reporting form, administered by a trusted third‑party vendor, that allows patients and community members to submit concerns confidentially and, if desired, anonymously.

Reports are received in a secure system and reviewed based on the information provided. Each report is handled with professionalism and discretion. Grace Health will not disclose a reporter’s identity without consent, although certain details may allow identification during an investigation. All reports made in good faith are taken seriously, reviewed fairly, and retaliation is strictly prohibited.

Thank you for supporting Grace Health’s commitment to maintaining a safe, respectful, and compliant environment for all.
Nature of the Concern:
Please select the category or categories that best describe your concern:

Other (Please specify):
Please describe the nature of your concern.
Please provide a clear and factual description of the concern. Include what occurred, how it occurred, and why you believe it may be inappropriate or non‑compliant.
Dates and Timeframes

When did the incident(s) occur?
Date(s):
Time(s):
Is the matter ongoing?
Location or Area Involved:
Where did the incident occur? (e.g., department, exam room, digital system, or off site location)
Individuals Involved:
If known, identify the individuals involved. Job titles or roles are sufficient if names are not known.
Supporting Information or Documentation
Do you have any documents, emails, records, screenshots or other information that may support this report?
Supporting Documentation Upload

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Prior Reporting
To your knowledge, has this concern been reported previously?

Yes - please indicated to whom or through which method:
Contact Information:

Complete this section only if you do not wish to remain anonymous.
Name

First NameLast Name
Email
example@example.com
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Disclaimer
Reports should be submitted in good faith and based on a reasonable belief that the information provided is accurate. Grace Health will review and address reports as appropriate; however, submission of a report does not guarantee a specific outcome. Confidentiality will be maintained to the extent possible, consistent with applicable law and the need to conduct a thorough review.
Should be Empty:

Anonymous Compliance and Ethics Reporting Form

Nature of the Concern:

Dates and Timeframes

Supporting Information or Documentation

Prior Reporting

Contact Information:

Disclaimer