HomeMy WebLinkAboutwhistleblower-reporting-form Whistleblower Reporting Form
1000 San Leandro Blvd., Suite 300, San Leandro, CA 94577 | Health.AlamedaCountyCA.gov | TEL (510) 618-3333 FAX (510) 351-1367
PURPOSE: The Alameda County Health (AC Health) Office of Compliance Services (OCS) receives,
tracks, and investigates complaints regarding: (1) deficiencies in the quality and delivery of health
care services; (2) suspected fraud, waste and abuse; (3) misuse of AC Health funds, grants, or other
resources; (4) violations of laws, the code of conduct, conflict of interest, AC Health policies and
procedures; and (5) other improper activities by AC Health employees or contractors.
OBJECTIVE: OCS manages the Whistleblower Program Confidential Compliance Line and, as
appropriate, investigates and seeks to resolve individual complaints.
RETALIATION: AC Health prohibits retaliation against any employee or contractor who, in good faith,
reports a compliance violation, seeks advice, or cooperates with or participates in an investigation.
Any act of retaliation should be reported immediately to OCS or Human Resources Department.
Reports will be routed to the appropriate office for review and investigation.
INSTRUCTIONS: You may email the form to ACHealth.Compliance@acgov.org, drop it off, or mail
the completed form to: Alameda County Health Office of Compliance Services
1000 San Leandro Blvd. Suite 300 | San Leandro, CA 94577
A descriptive and complete report allows OCS to identify, investigate, and assess root causes, which
in turn helps impacted AC Health departments timely implement corrective actions and preventive
measures, when necessary. Reporters should consider the following best practices to help ensure
that allegations can be efficiently investigated and effectively addressed.
Provide your contact information (e.g., phone number or email). This allows
investigators to follow up with questions and request additional information.
Provide the names of any witnesses and speciflc incident details (e.g., date, time, and
location). General statements such as “ask anyone” are not helpful; please be as
speciflc as possible.
If available, provide copies of any supporting evidence, including invoices, photos, video
footage, or email correspondence.
Clearly and concisely describe what aspect of the alleged conduct is improper and why
you believe it is improper. OCS responds to speciflc allegations and does not investigate
general reports, suggestions, or speculation.
Clearly identify the name of the individual alleged to have engaged in improper conduct
and the AC Health department or contractor where they work. If the name is unknown,
provide any other identifying information.
After submission, your report will be reviewed. If additional information is needed and contact
information has been provided, you may be contacted within 5 business days. Alternatively, you may
call or email us for an update.
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PART I: YOUR INFORMATION
Section A: Contact Information (Do NOT complete this section if flling anonymously)
First Name: Last Name:
Phone Number: Email Address:
Best Contact Time:
☐Morning (8 AM-12 PM)
☐Afternoon(12 PM -5 PM)
Work Location & Address:
Section B: Your Employment Status
☐AC Health Employee (☐Active ☐ Former)☐Intern or Volunteer
☐AC Health Contractor/Vendor/Consultant ☐Other (please specify):
PART II: ALLEGATION DETAILS
Please provide a summary of your complaint, including a chronological sequence of events if
applicable. If you have more than one allegation, please number each one. Note: if submitting an
anonymous report, please provide as much detail as possible so the matter can be properly
reviewed and investigated.
1.Provide a summary of your complaint. What did the subject(s) do or fail to do that you believe
was improper?
2.When (e.g., date, time) and Where (e.g., location) did the incident occur?
3.Who was involved in this incident (e.g., names and titles of staff involved)? Do not include
client names?
4.Are there any witnesses to the incident(s)? If so, please provide their names, contact
information, and/or identifying information.
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5.What rule, regulation, law or policy do you believe was violated?
6.Briefiy describe how you believe our office can assist you regarding your complaint?
7.Is there any additional information you would like to share?
PART III: OTHER ACTIONS
1.Have you reported this incident to your manager or someone within your department or
organization?
☐Yes (to whom? What happened?)
☐No (why not?)
2.Have you reported this incident to any other Organizations/Agencies? ☐ Yes ☐ No
a)Which Organization/Agency?
b)When did you report it (e.g., date,
year)?
c)What is the status of that
complaint?
☐Open ☐ Under Investigation ☐ Closed ☐ Unknown
PART IV: CERTIFICATION
I certify that the information provided in this complaint is submitted in good faith and is true,
complete, and correct to the best of my knowledge. I understand that information may be used
and disclosed on a need-to-know basis for purposes of review and investigation.
Signature: __________________________________________ Today’s Date: _________________