1.I wish to report a concern to NIS Compliance Office regarding:

ComplianceHIPPA

2.Please provide a description of your concern including the specific program or site involved, details of the concern, names of agency associates involved and any actions you may have taken regarding your concern.

3.I would like my concern to be anonymous:

YesNo

4.I am willing to be contacted regarding my concern:

YesNo

5.My relationship to NIS is:

Person Receiving ServicesFamily Member of a Person Receiving ServicesBoard MemberOther Service ProviderCommunity MemberStaff MemberOther (please specify)