Medical Whistleblower Registration Survey- Medical Whistleblower Lawerence KS

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1. Are you ...

MaleFemale

Are you ...

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2. How old are you?

How old are you?   18-34 35-54 55-65 65+

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3. Are you a member of a privileged class under Civil Rights Law, ADA or other Legislation?

Are you a member of a privileged class under Civil Rights Law, ADA or other Legislation?   Yes No Don't Know

4. What civil rights class do you belong to?

	Racial	Religious	National Origin	Sex	Sexual Orientation	Disabled
Primary	*What civil rights class do you belong to? Primary Racial	Primary Religious	Primary National Origin	Primary Sex	Primary Sexual Orientation	Primary Disabled
Secondary	Secondary Racial	Secondary Religious	Secondary National Origin	Secondary Sex	Secondary Sexual Orientation	Secondary Disabled

Other (please specify)

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5. Please give us your name, address, phone number, email address, FAX and any other contact information.

Please give us your name, address, phone number, email address, FAX and any other contact information.

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6. What did you report?

What did you report?   Medical Abuse

Medical Neglect

Medical Fraud

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7. Have you experienced Whistleblower Retaliation

Have you experienced Whistleblower Retaliation   Yes No

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8. Have you had legal representation during your whistleblowing experience?

Have you had legal representation during your whistleblowing experience?   Yes No

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9. To whom did you report?

To whom did you report?   Up the chain of command, hospital, clinic or corporation Local Law Enforcement State Law Enforcement Federal Law Enforcement Office of the the Inspector General Merit Protections Board National Secuirty/Intelligence Agency (FBI,CIA,NSA,DIA) Occupational Safety and Health (OSHA) Nuclear Regulatory Commission (NRC) Food and Drug Administration (FDA) Department of Energy (DOE) State Department of Health SRS Environmental Protection Agency (EPA) United States Department of Agriculture (USDA) Securities & Exchange Commission (SEC) Department of Labor (DOL) Other State Agency Other Federal Agency Other

Other (please specify)

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10. What is your professional specialty?

What is your professional specialty?   MD Medical Doctor O.D. Osteopathic Doctor DVM Veterinary Doctor PharmD Pharmacist Pharmacy Techician Psychologist PhD Psychiatrist MD Licensed Therapist RN Registered Nurse LPN Licensed Practical Nurse PA Physicians Assistant	MT Medical Technician Medical Technologist Chiropractor Dentist Health Care Aid Attorney CPA Certified Public Accountant Hospital/Clinic Staff Hospital CEO Hospital CFO Medical Research Professional	Public Health Official Veterinary Research Environmental Officer Banking Official Intelligence Official Miliary/Defense Official Patient Advocate Medical Records Administrative Staff Law Enforcement Officer/Official Social Worker MSW Other
Other (please specify)