Compliance Issue Reporting Form

To report an issue with staff member compliance, please complete the form below. Alternatively, you can use our Member Feedback form or for all other inquiries, please complete our contact form.

Name of staff person(s) this report is being submitted for:(Required)

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

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

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

This may include documents, photographs, etc. We may contact you for this information after you submit this report.

How did you become aware of the incident(s)?

For example: witness first hand, heard it from another person, etc.

Your Contact Information:

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:

i. Your report will no longer be anonymous if you choose to provide this information.
ii. If you’d prefer to have follow up from the Compliance Committee on any results related to your concern, the Compliance Committee will not be able to contact you if you choose not to provide this information.
iii. If you choose not to provide this information and there is a need for additional information in order to further consider your concern, the Compliance Committee may not be able to substantiate your concern if you do not provide this information.

Would you like follow up from the Compliance Committee?

Yes

Behavioral Health Alliance of Rural Pennsylvania (BHARP)

301 Science Park Rd
State College, PA 16803

Phone: 814-826-2952

Email: theruraldifference@bharp.org