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