Confidential Reporting Order Number This form is a secure method to privately report any concerns or issues that you may have seen or experienced at one of our clinical sites. All reports will be reviewed by our Ethics and Compliance Officer.. First Name (Optional) Last Name (Optional) Email Address (Optional) Are you a patient or an employee?: (This is optional) Patient Family Member or Friend of Patient Employee Former Employee Who are you reporting? *(Required) * Reception Staff Billing or Eligibility Staff Nursing Staff Doctor, Nurse Practitioner or Physician Assistant Dentist Dental Hygienist or Assistant Laboratory Cleaning Crew, Maintenance Crew, Etc. Security Officer Management Board Member Other Select Location: *(Required) * Brownwood, 104 Southpark Brownwood, 3804 Hwy. 377 S. De Leon, 1100 W. Reynosa Ave. Stephenville, 135 River North Blvd. Date the problem occurred: *(Required) * Time the problem occurred: (This is optional) Subject: *(Required) * Please describe your concern. Please be as detailed as possible. *(Required) *
