Today's Date:* Date Format: MM slash DD slash YYYY The process for reporting a concern is simple: First, please tell us what happened by selecting the topic that best describes the issue you are reporting. Once you have completed the form, and attached any/all supporting documentation, then click submit to transmit. To request an update on a filed report, you may email your request to firstname.lastname@example.org include in the subject line “Status Update” or contact the Compliance Officer directly. WHAT TYPE OF ISSUE ARE YOU REPORTING? Please select the topic that best describes the issue you are reporting:*Discrimination Statements or actions based on age, race, color, national origin, sexual orientation, gender, disability or religion that are the basis for employment, promotion or compensation decisionsHarassment - Sexual Statements or actions expressing unwelcome sexual advances, requests for sexual favors, unsolicited physical contact or propositions, unwelcome flirtations, or offensive verbal or visual expressions or physical conduct of a sexual nature.Harassment - Workplace Persistent statements, conduct or actions that are uninvited, degrading, offensive, humiliating or intimidating and create an unpleasant or hostile environment.Retaliation or Retribution Statements or actions discharging, demoting, suspending, threatening, harassing or discriminating against an employee because of any lawful act taken by such employee in connection with reporting a violation of law or policy, filing a complaint, or assisting with an investigation or proceeding.Conflict of Interest - Personal Any personal interest, any business or professional activity or relationship, prior or current employment, or any obligation that may interfere with the ability to objectively perform job duties and responsibilities or impair independence and objectivity.Inappropriate Behavior Statements or actions that are not harassing in nature, but are believed to be unsuitable for the workplace.Unfair Employment Practices Employment decisions, practices or disciplinary actions that are believed to be unfair regardless of whether they are the result of job performance, changes in business needs or other business related decisions.Environment, Health and Safety Conduct, actions, policies or practices that either violate local, provincial or federal environmental, health or safety laws or regulations or may cause or result in potentially hazardous conditions that impact the environment or the health or safety of employees, customers or others.Substance Abuse The unlawful use, possession, sale, conveyance, distribution, concealment, transportation or manufacture of illegal drugs, intoxicants, controlled substances or drug paraphernalia in the workplace or while conducting business.Threats and Physical Violence Statements or actions that threaten acts of violence or the presence of weapons, firearms, ammunition, explosives or incendiary devices in the workplace, on work premises or in work vehicles.Accounting and Auditing Practices Statements or actions that violate or conflict with either internal policies, procedures, or practices or government regulations related to the detailed reporting of the financial state or transactions of an organization or the examination, verification, or correction of its financial accounts.Conflict of Interest - Financial Any financial interest, any business or professional activity, prior or current employment, or any obligation that may interfere with the ability to objectively perform job duties and responsibilities or impair independence and objectivity.Gifts, Bribes and Kickbacks Payments, payments in kind, gifts, bribes, extensions of credit or benefits extended to or received by customers, employees, suppliers, vendors, competitors, directors, officers, auditors, government employees, government officials or agencies, or other parties that are unlawful, improper, or designed to influence business decisions or political processes.Trading on Inside Information The purchase or sale of stock or other securities based on non-public and material information obtained during the course of employment or providing such information to another person who purchases or sells stock or other securities based upon that information.Customer Relations Statements or actions that negatively impact or interfere with customers, customer relationships or customer agreements.Disclosure of Confidential Health Information - HIPAA The unauthorized or illegal disclosure, copying, duplication, misuse or release of protected personal data including employment, medical, financial and individually identifiable health information in violation of privacy laws.Disclosure of Confidential Information The unauthorized or illegal disclosure, copying, duplication, misuse or release of confidential or personal data including but not limited to employment, financial, medical and health, customer lists, contracts, business plans, personnel records or other property marked or generally regarded as confidential or trade secrets.Misuse of Resources The improper, unauthorized or unlicensed use of property or resources for non-business related reasons or purposes, including improper use of systems and timekeeping.Promotion and Advertising - Pharmaceutical Unauthorized, improper or illegal dissemination of materials promoting non-approved pharmaceuticals or offlabel use of drug products. Violation of corporate policy or regulatory requirements for promotional events by pharmaceutical company representativesTheft The unauthorized removal or taking of supplies, equipment, furniture, fixtures, products, cash, merchandise or other tangible property.Unauthorized Discounts or Credit The unauthorized extension of discounts or credit to customers, employees, suppliers, or vendors.Guidance Request Request for guidance, interpretation, or other information regarding matters of law, regulations, or policies.Other Statements actions or policies that concern the caller but are not currently resulting in harm, injury or corporate liability and cannot be included in any other category.Antitrust or Fair Trading Discussions or agreements with competitors about prices or credit terms, submission of bids or offers, allocation of markets or customers, restrictions on production, distribution or boycotts of suppliers or customers that would result in monopolization or anticompetitive markets.Espionage or Sabotage Actions that result in the gathering, receipt or acceptance of non-public confidential information or trade secrets about competitors to gain a competitive advantage or the deliberate destruction, disruption or damage to a competitor's equipment or property for competitive advantage or gain.Falsification or Destruction of Information Statements or actions that encourage or result in unlawful, untimely, false or intentional misrepresentation, concealment or destruction of information in order to deceive or mislead.Customer Care Policies, practices, or individual actions causing unacceptable quality of care given to customers. Includes negligence, medical errors, accidents, and abuse.Quality Control Complaints about product or service quality or effectiveness; allegations of product tampering; violation of policies and practices for manufacturing controls; allegations of non-compliance with product standards or service delivery.Quality Control - Medical The improper, unauthorized or unlicensed use of medical equipment, supplies or pharmaceuticals; noncompliance with maintenance, storage and labeling requirements.Research Misconduct Improper or fraudulent documentation of test results or other research procedures or findings in order to deceive or mislead; non-compliance with required practices and procedures; unethical or noncompliant treatment of research subjects.Issue Details: What happened? Please provide a brief description of the issue?*Does the issue involve unethical or noncompliant treatment of human subjects?*YesNoI do not knowDoes this issue involve unethical or noncompliant treatment of animal subjects?*YesNoI do not knowPlease describe your concern in more detail.*What is your involvement in the issue?*It happened to meI was involvedI observed itI overheard itSomeone told me about itIs this an ongoing issue?*YesNoI do not knowWhat is the date of the most recent occurrence?* Date Format: MM slash DD slash YYYY Have you reported this issue to anyone within the organization?*YesNoDo you believe that anyone has taken steps to hide this issue?*YesNoI do not knowWhere did the issue occur?*At a location of PHSAt an off-site locationI do not knowWhat is your relationship to PHS?*EmployeeContractorVendorCustomerOtherI do not knowDo you wish to remain anonymous?*YesNoHave you discussed this issue with management?*YesNoWhere did it happen? Please identify the PHS location, or Business Associate location where the issue occurred.*Please list the people involved in the issue other than yourself, and indicate each person's role in the issue:*NameRole in Issue*Relationship to PHS:*EmployeeContractorVendorCustomerOtherI do not knowHow did you become aware of this confidential reporting service?*PHS WebsiteCo-WorkerEmployee HandbookCompliance TrainingCompliance NewsletterCompliance Manual (Code of Business Conduct)SupervisorEmployee MeetingOtherIs this the first time you have used web reporting to report a concern?*YesNoHOW DO WE CONTACT YOU? PLEASE DO NOT DISCLOSE YOUR CONTACT INFORMATION IF YOU WISH TO REMAIN ANONYMOUS! All others, please provide the following information: NameEmail Address Contact NumberAttachments: Upload any supporting documents with your compliance issue. Drop files here or Accepted file types: jpg, pdf, docx. To request an update on a filed report, email your request to email@example.com and include “Status Update” in the subject line.