Complete Healthcare Compliance Manual

Investigation completed by:

Date investigation completed:

Employee(s) involved:

Date investigation report completed (if different from above):

Employee’s manager:

Employee(s) date of hire:

Name of person(s) who raised the issue:

Date issue was brought to attention:

Description of allegations (check all that apply):

• Racial discrimination/harassment

• Age discrimination/harassment

• Gender discrimination/harassment

• Discrimination/harassment based on national origin

• Discrimination/harassment based on color

• Religious discrimination/harassment

• Discrimination/harassment based on disability or medical condition

• Ancestry discrimination/harassment

• Discrimination/harassment based on marital status

• Discrimination/harassment based on sexual orientation

• Discrimination/harassment based on gender identity

• Discrimination/harassment based on genetic information

• Discrimination/harassment based on pregnancy

• Discrimination/harassment based on veteran status

• Retaliation

• Unfair treatment

• Favoritism

• Theft or misappropriation of intellectual

• property/confidential information

• Fraud

• Falsification of records

• Violation(s) of gifts/entertainment policy

• Conflicts of interest

• Threats or violence in the workplace

• Privacy policy violation

• Safety violation

• Other inappropriate behavior

Brief summary of allegations:

Is there any interim action that was taken while the investigation was pending?

Description of Company policies/employee agreements that might be involved (where marked, attach a copy of those policies to the final report):

Are there likely documents or other information that might lead to information that

would support or refute the claims? If so, identify such documents and what steps will be

taken to locate those documents or items:

If you did not interview any of the persons identified by the person complaining or about

whom the complaint was made, state the reason here:

List of interviews conducted:

Name/Title:

Date:

Length of interview:

Notes:

Name/Title:

Date:

Length of interview:

Notes:

Name/Title:

Date:

Length of interview:

Notes:

Name/Title:

Date:

Length of interview:

Notes:

Name/Title:

Date:

Length of interview:

Notes:

Name/Title:

Date:

Length of interview:

Notes:

Summarize the course of the investigation and witness interviews:

Summary of interviews:

Summary of investigation:

Findings and conclusions of investigator:

Prior relevant incidents:

Recommendations for next steps:

Follow-up: