Anonymous Procedure for Reporting Perceived Compliance Deficiencies

Anonymous Procedure for Reporting Perceived Compliance Deficiencies No adverse action or any form of retaliation will be taken against you for the good faith reporting of perceived compliance deficiencies or unethical or illegal conduct. If you wish to remain anonymous, do not provide any information that might compromise your anonymity; however, please do provide sufficient information for your concern to be investigated.
Date: ___________________ Department Involved: _______________________________ Names Involved: ______________________________ ______________________________ ______________________________	Note: Department and names are not required though it may be difficult to investigate your concern without this information.
Nature of deficiency:__________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ Others who have knowledge of the problem(s), or who may have knowledge of the situation: __________________________________ __________________________________ __________________________________ Have you discussed this concern with your supervisor? ________Yes ________No Details of discussion:__________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ Have you discussed this concern with anyone else? ________Yes ________No If yes, when? ________________ With who (optional):___________________________ Details of discussion:__________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ Was anything put in writing about this? _________Yes __________No Can you provide detail? __________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ How did you find out about this concern? ____________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ Are you willing to meet to discuss further? __________Yes __________No Anonymity Requested: ___________Yes ___________No If No, please provide: Name:______________________________ Department: _________________________ Phone: ______________________________ Mail To: William F. Hickey Chair, Compliance Assurance Advisory Council Dartmouth College 11 Rope Ferry Road Hanover, NH 03755-1404

Last Updated: 12/23/08