Concern Reporting Form
Report a concern, describe what happened, and share any details that will help review it. Please complete all relevant fields.
Reporter Information
Reporter Name
*
First Name
Last Name
Email Address
*
example@example.com
Preferred Contact Method
*
Email
Phone
No Follow-up
Concern Details
Concern Title
*
Concern Category
*
Safety
Conduct
Harassment
Discrimination
Fraud
Policy Violation
Workplace Conflict
Other
Concern Date
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Location or Department
Detailed Concern Description
*
Urgency / Severity
*
Low
1
2
3
4
5
6
7
8
9
Critical
10
1 is Low, 10 is Critical
Impact and Follow-up
How often does this issue occur?
*
Once
Occasionally
Frequently
Continuously
Other
Impact level
*
Low impact
1
2
3
4
5
6
7
8
9
High impact
10
1 is Low impact, 10 is High impact
Immediate action already taken
Preferred follow-up outcome
*
Please Select
No further action needed
Investigate and respond
Schedule a follow-up discussion
Escalate to management
Other
Submit Concern
Should be Empty: