Corporate Compliance Reporting Form

Springbrook is committed to conducting its business in a manner that provides quality services and complies fully with applicable laws, regulations, guidance, and program requirements. All staff, board members, volunteers, and contractors have a responsibility to promptly report, any activity that appears to violate applicable laws, rules, regulations or ethical standards directly to the Compliance Officer. This may be done in person, directly by phone to the QA department, using the Springbrook Compliance Hotline (607) 286-7171 ext. 299, or via this online submission form.

No individual who, in good faith, reports a violation or a suspected violation shall suffer harassment, retaliation, or adverse employment consequences. Any report shown to have not been made in good faith, will be viewed as a serious offense and will lead to disciplinary action, up to and including termination. Failure to report misconduct may also result in disciplinary action, up to and including termination.

Springbrook will make every effort to treat all reports confidentially and to protect the anonymity of the individual who reported the information.

Please note: If you choose to remain anonymous and do not provide a way for the Compliance Officer to contact you it may be much more difficult for Springbrook to conduct a thorough investigation. If you wish to remain anonymous but have information to share consider contact through a throwaway or anonymous email address.

Do you wish to remain ANONYMOUS for this report?*

YesNo

Name

First NameLast Name

Phone Number

Please enter a valid phone number including area code.

Email

example@example.com

What is your relationship to Springbrook

Where did the alleged misconduct, violation, and/or non-compliance activity take place?*

We recognize that this incident may not have occurred in a particular location. However, if this incident was observed in some documentation or business transactions, please indicate this accordingly.

Date of Incident

Date

Please identify the person(s) engaged in the alleged misconduct, violation, and/or non-compliance.*

Include first name, last name, and title.

Please identify any person(s) who have attempted to conceal this issue and the steps they took to conceal it.

Include first name, last name, and title. Examples: Ignored it; Changed documents; Said it was not a problem; Said they would look into it

How did you become aware of the alleged misconduct, violation, and/or non-compliance?*

Details of Incident*

Please provide a detailed description of the alleged misconduct, violation, and/or non-compliance activity. Include locations of witnesses and any other information that could be valuable in the evaluation and ultimate resolution of this situation. Please take your time and provide as much detail as possible, but exercise care to not provide details that may reveal your identity, unless you wish to do so. It may be important to know if you are the only person aware of the situation.