HTC Compliance Reporting Form - Human Technologies Corporation

HTC Compliance Reporting Form
Date:
Name & department of individual writing this report (unless you wish to remain anonymous*):
How do you wish the Quality and Compliance Specialist to contact
you for follow-up?
Check one:
Email/phone: ___at HTC
___at Home
Phone Number:
Please provide phone number and/or email address.
______________________________
Email address:
_______________________________
What are you reporting? Please explain your concern and why it concerns you.
What are the date(s) or period for your concern?
Department(s) involved:
Any other individuals and/or department(s) involved (unless they wish to remain anonymous):
Are there any supervisors or department managers you have spoken If yes, what actions did they take and what
to about your concern?
were you told?
Any additional information you would like to share?
Instructions: Any Human Technologies Corporation employee, physician or agent may
complete this form if you feel there was/is a situation of potential non-compliance with NY State
regulations, Federal regulations, HTC’s own policies or HTC’s Corporate Compliance Program.
Please complete this form and send directly to: Lisa Volo, Corporate Compliance Officer, 2260
Dwyer Avenue, Utica, NY 13501 or [email protected] 315-724-9891 ext. 141
Note: *The Corporate Compliance Officer will maintain this report in a confidential manner, which means that
your identity will not be disclosed unless, absolutely necessary. It is helpful for you to allow this to be handled
confidentially rather than anonymously, so that the Compliance Officer can contact you with any questions and with
the outcome of her investigation. If you choose to remain anonymous, the Compliance Officer may not be able to
further the investigation or notify you directly of the outcome of any investigation. However, you may contact Lisa
Volo directly at 315-724-9891 extension 141 if you have any further information or questions.
5-20-2011 Revision A
HTC Corporate Compliance Plan Article IX (c)