Research Compliance Violation Report Form

This form is for reporting an alleged violation of state or federal requirements which the Chief Compliance Officer has jurisdiction to investigate. Note: This form is not for reporting grievances or general complaints. Follow the proper procedure for such complaints.

Printable Version

PLEASE COMPLETE ALL OF THE FOLLOWING INFORMATION:

Today's Date

First Name (optional):

Last Name (optional):

Email (optional)

Phone # (optional):

Position (optional):

PLEASE NOTE: Although this information is not required for an investigation to be conducted, the Chief Compliance Officer will be unable to report findings back to you or to obtain additional information if needed without this information. Western Michigan University Homer Stryker M.D. School of Medicine does not permit retaliatory action against employees or contractors who, in good faith, report violations.

Please provide a detailed description/report of the violation below:

If known, please provide the department and location where this activity took place:

Provide the names of employees or others you believe are involved in or aware of the violation:

How did you become aware of this activity?

To your knowledge, how long has this activity been going on?

Do you think management is aware of this problem?

Yes

Unknown

Has this violation been reported to anyone previously within the organization?

Yes

Unknown

If yes, to whom and when?

Can we contact you if we have additional questions?

Yes

If yes, how & when do you prefer to be contacted? Please provide relevant contact information & available timeframes.

What is the federal/state/policy requirement that you believe has been violated?

Please include any supporting documentation you may have with your submission, or indicate where that documentation may be found

Unlimited number of files can be uploaded to this field.
6 MB limit.
Allowed types: gif, jpg, png, bmp, eps, tif, pict, psd, txt, rtf, odf, pdf, doc, docx, ppt, pptx, xls, xlsx, xml, bz2, dmg, gz, jar, rar, sit, svg, tar, zip.

Where documentation can be found:

Research questions or concerns can also be directed to the WMed Chief Compliance Officer:
Lori A. Straube, MBA
Associate Dean for Administration and Finance, and Chief Compliance Officer
1000 Oakland Drive, Kalamazoo, MI 49008-8010
Email: lori.straube@med.wmich.edu or compliance@med.wmich.edu

or through the anonymous hotline:

Compliance and Concern Hotline
Website: https://www.lighthouse-services.com/wmed
Phone: 1.833.222.1416