* = Required Information

Complainant Information

To ensure employee cooperation, Jannic Health Services will not take any retaliatory action or retribution against any employee who has submitted a report of a suspected violation or who has participated in an investigation of a suspected violation in good faith. Any employee who takes retaliatory action or retribution against another employee who has either reported a suspected violation or participated in an investigation of a suspected violation will be subject to disciplinary action.

Summary of Complaint/Violation

Additional Information (Please include dates, location and/or other specifics regarding the suggestions/recommendations/concerns/complaints as well as names, if known, of the alleged violators or those individuals or entities who you may know have information about the matter. Use additional sheets and provide copies of pertinent documents if available.)

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