Compliance Issue Reporting Form

To report a compliance concern regarding a BHARP staff or Board of Directors (BOD) member or a BHARP contractor, please complete the form below. For any other feedback, please use our Member Feedback form. For all other inquiries, please complete our contact form.

Name(s) of BHARP staff, BOD member(s) and/or BHARP contractor(s) for which this form is being submitted:(Required)

Please check the box of which the issue is in potential violation. Check all that apply:(Required)

Federal/State Regulation

BHARP Policy

BHARP Standard of Conduct

Unsure

Please describe the specific compliance concern you are reporting.(Required)

Please include as many details as possible related to your concern: the who, what, where, why, when, how, etc.:

Please describe the evidence you have in as much detail as possible:(Required)

This may include emails, documents, photographs, etc. BHARP may contact you for this information after you submit this form.

How did you become aware of the concern(s)?(Required)

For example: witnessed in person, heard it from another person, etc.

Your Contact Information: (Optional)

Optional – Provide your name, phone number, and email address so that the Compliance Committee may contact you for more information if necessary.

Your Contact Information - Important Note:

· Your report will no longer be anonymous if you choose to provide your contact information.
· If you’d prefer to have follow up from the BHARP Compliance Committee on any results related to your concern, you must provide your contact information.
· If you choose not to provide your contact information and there is a need for additional information/follow-up in order to further consider your concern, the BHARP Compliance Committee may not be able to conduct a thorough investigation.

Would you like follow-up from the BHARP Compliance Committee?

Yes

Behavioral Health Alliance of Rural Pennsylvania (BHARP)

301 Science Park Rd
Suite #308
State College, PA 16803

Phone: 814-826-2952