Ethical Issue Submission Form

Introduction

This form will be utilized to submit ethical issues to the committee for review and resolution. Submissions may be made anonymously, or you may provide your contact details should you desire to be contacted regarding the matter you have submitted.

1. Reported by:

(Optional)

2. Email address:

(Optional)

3. Severity of issue *This question is required.

4. Priority of issue *This question is required.

5. Topic/area (please enter a word or short phrase describing the issue's topic). For example, if the issue concerns access to patient medical records, the topic could be "HIPAA". If it relates to unsecured payments from clients, the topic could be "Internal Controls" and so on.

6. Please provide a detailed description of the issue identified. Include processes, policies, procedures, etc as applicable. The more details you provide will help the committee to ensure the issue can be addressed appropriately and timely. *This question is required.