HVCS Client Complaint Disclosure Form

THIS FORM IS NOT A 911 OR EMERGENCY SERVICE.

Do not use this site to report events presenting an immediate threat to life or property. Reports submitted through this service may not receive an immediate response. If you require emergency assistance, please contact your local authorities.

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* 1. Location where this incident occured

Hawthorne

Mount Vernon

Spring Valley

Kingston

Poughkeepsie

Newburgh

Monticello

SEP Van

PRO Van

Other (please specify)

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* 2. Do you wish to remain anonymous for this report?

Yes

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* 3. Name (First and Last)

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* 4. Phone Number

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* 5. Email address

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* 6. Best time for communication with you:

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* 7. Is it ok to leave a message?

Yes

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* 8. What is your relationship to HVCS?

Employee

Former employee

Client

Family member of client

Contractor

Vendor/Supplier

Other (please specify)

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* 9. Please identify the person(s) engaged in this incident:

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* 10. Have you previously reported this incident?

Yes

Don't know

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* 11. If yes, then to whom? What was the response?

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* 12. Please provide the specific or approximate time this incident occurred:

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* 13. How long do you think this problem has been going on?

Once

One week

1 to 3 months

3 months or more

More than a year

Don't know

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* 14. How did you become aware of this incident?

It happened to me

I observed it

Told to me by a co-worker

Told to me by someone outside of the comapny

Told to me by the client

Told to me by the client's family member

Overheard it

Accidentally found a document or file

Other (please specify)

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* 15. Please identify any persons who have attempted to conceal this problem and the steps they took to conceal it:

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* 16. * Please provide all details regarding the alleged violation, including the locations of witnesses and any other information that could be valuable in the evaluation and ultimate resolution of this situation.